HESI SAUNDERS ONLINE NCLEX (2E) MODULE 5 Questions and
Answers| Latest Update 100% Solved | Guaranteed Success
A nurse in a long-term care center notes that an employee is constantly calling in sick. Which
action should the nurse take initially to handle this problem?
a. Reporting the employee to administration
b. Documenting the employee s behavior in the personnel file
c. Telling the employee that she will be fired if she calls in sick again
d. Reminding the employee of the employment standards of the agency d. Reminding the
employee of the employment standards of the agency
Rationale: When an employee demonstrates an unacceptable level of absenteeism, the nurse
must first remind the employee of the employment standards of the agency. Sometimes an
employee does not know or has forgotten the existing standards, and a reminder with no
threats or discipline is all that is needed. When the oral reminder does not result in a change in
behavior, the reminder should be placed in writing. If the written reminder fails, the employee
should be granted a day of decision to determine whether to accept the standards for work
attendance. Pay may be given for this day (depending on the agency protocol) so that it is not
interpreted as punishment, and the employee must return to work with a written decision. If
the employee decides not to adhere to standards, her employment with the agency is
terminated. Reporting the employee to administration, documenting the employee's behavior
in her personnel file, and telling the employee that she will be fired if she calls in sick again are
not appropriate initial actions.
Test-Taking Strategy: Use the process of elimination, noting the strategic word "initially."
Focusing on the data in the question and noting that there is no information to indicate that this
employee has been approached about his or her behavior in the past will direct you to the
correct option. Review the procedure for handling unacceptable behavior related to
employment standards if you had difficulty with this question.
A nurse is planning client assignments for the day. Which task should the nurse assign to the
nursing assistant (unlicensed assistive personnel)?
,a. Preprocedural teaching for a client scheduled for a cardiac stress test
b. Dressing change instructions for client who had a mastectomy 2 days ago
c. Reporting abnormal lab values the health care provider for a client scheduled for a
laparoscopic cholecystectomy
d. Recording the urinary output for a client with renal calculi whose urine must be strained
d. Recording the urinary output for a client with renal calculi whose urine must be strained
Rationale:
The nurse is legally responsible for client assignments and must assign tasks on the basis of the
guidelines of the state nursing practice act and the job descriptions set forth by the employing
agency. The nursing assistant has been trained to measure, collect, and strain urine. The nurse
would provide instructions to the nursing assistant regarding the task, but the task is within the
role description of a nursing assistant. A client scheduled for a cardiac stress test requires
preprocedure preparation for the test, which is not a task within the role description for a
nursing assistant. The nursing assistant cannot provide dressing change instructions to a client
who has had a mastectomy. It is not within the role description of the nursing assistant to report
abnormal laboratory values to the health care provider.
Test-Taking Strategy: Note that the question asks for the tasks to be assigned to the nursing
assistant. When asked questions related to delegation, think about the role description of the
employee and the needs of the client. Eliminate the comparable or alike options that are
invasive and require higher level of skill. For the nursing assistant, select the tasks that are
noninvasive and do not require a high skill level, meaning that assessment, teaching, and
monitoring are inappropriate tasks. Review the guidelines related to delegation to a nursing
assistant if you had difficulty with this question.
A nurse is working in an urgent care center during the night shift. A client arrives at the center
for treatment after a sexual assault. The nurse has never cared for anyone who has been raped.
To determine the necessary actions in regard to this client's injury, the nurse should take which
action?
,a. Ask a medical assistant.
b. Call the nurse in charge of the day shift.
c. Ask the police officers who brought the client to the center.
d. Check the unit policy for the protocol for the care of clients who have been sexually assaulted
d. Check the unit policy for the protocol for the care of clients who have been sexually
assaulted.
Rationale:
A policy or procedure is a designated plan or course of action to be taken in a specific situation.
Written copies of all policies are usually placed in a policy manual that is available in each
department or may be available online. Specific unit policies are sometimes referred to as
protocols. The policy or protocol for a client who has been raped will describe the physical,
psychosocial, and legal responsibilities of the nurse. Calling the nurse in charge during the day
shift or asking an medical assistant or the police officers who brought the client into the center
is inappropriate. If the nurse needs additional information after reviewing the policy or protocol,
it would be most appropriate to contact the agency nursing supervisor of the night shift.
Test-Taking Strategy: Use the process of elimination, recalling the legal implications related to
providing care. Note the incorrect comparable or alike options that suggest obtaining
information from other individuals. Review the purpose of organizational policies, procedures,
or protocols if you had difficulty with this question.
A nurse at the long-term care unit on the 11 p.m. to 7 a.m. shift is gathering the nursing staff
together to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has
an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol
intoxication. Which action is most appropriate for the nurse to take?
a. Contact the nursing supervisor.
b. Ask the staff member how much alcohol she has consumed.
c. Tell the staff member that she is not allowed to administer medications.
, d. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.
a. Contact the nursing supervisor.
Rationale:
When a staff member reports to work in a state of alcohol intoxication, the nurse notes the
signs objectively and asks a second person to validate these observations. The nurse also
contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in
judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated
nurse is removed from the situation. The incident is recorded and the nurse describes the
observations, states the action taken, indicates future plans, and has the staff member sign and
date the memo of the recorded incident. Refusal to sign and date the memo should be noted by
the nurse and a witness. Neither asking the staff member to rest in the nurses' lounge until the
effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to
administer medications removes the staff member from the client care area, jeopardizing client
safety. Asking the staff member how much alcohol she has consumed is confrontational and
irrelevant.
Test-Taking Strategy: Use the process of elimination, keeping in mind that client safety is the
priority. Asking the staff member how much alcohol she has consumed is irrelevant, so
eliminate this option. Next eliminate the comparable or alike options that do not involve
removal of the staff member from the client care area. Review nursing responsibilities when
substance abuse is suspected in a staff member if you had difficulty with this question.
A nurse discovers that another nurse has administered an enema to a client even though the
client told the nurse that he did not want one. Which is the most appropriate action for the
nurse to take?
a. Contact the client's health care provider.
b. Report the incident to the nursing supervisor.
c. Tell the client that the nurse did the right thing in giving the enema.
d. Confront the nurse who gave the enema and tell the nurse that she is going to be charged
with battery.
Answers| Latest Update 100% Solved | Guaranteed Success
A nurse in a long-term care center notes that an employee is constantly calling in sick. Which
action should the nurse take initially to handle this problem?
a. Reporting the employee to administration
b. Documenting the employee s behavior in the personnel file
c. Telling the employee that she will be fired if she calls in sick again
d. Reminding the employee of the employment standards of the agency d. Reminding the
employee of the employment standards of the agency
Rationale: When an employee demonstrates an unacceptable level of absenteeism, the nurse
must first remind the employee of the employment standards of the agency. Sometimes an
employee does not know or has forgotten the existing standards, and a reminder with no
threats or discipline is all that is needed. When the oral reminder does not result in a change in
behavior, the reminder should be placed in writing. If the written reminder fails, the employee
should be granted a day of decision to determine whether to accept the standards for work
attendance. Pay may be given for this day (depending on the agency protocol) so that it is not
interpreted as punishment, and the employee must return to work with a written decision. If
the employee decides not to adhere to standards, her employment with the agency is
terminated. Reporting the employee to administration, documenting the employee's behavior
in her personnel file, and telling the employee that she will be fired if she calls in sick again are
not appropriate initial actions.
Test-Taking Strategy: Use the process of elimination, noting the strategic word "initially."
Focusing on the data in the question and noting that there is no information to indicate that this
employee has been approached about his or her behavior in the past will direct you to the
correct option. Review the procedure for handling unacceptable behavior related to
employment standards if you had difficulty with this question.
A nurse is planning client assignments for the day. Which task should the nurse assign to the
nursing assistant (unlicensed assistive personnel)?
,a. Preprocedural teaching for a client scheduled for a cardiac stress test
b. Dressing change instructions for client who had a mastectomy 2 days ago
c. Reporting abnormal lab values the health care provider for a client scheduled for a
laparoscopic cholecystectomy
d. Recording the urinary output for a client with renal calculi whose urine must be strained
d. Recording the urinary output for a client with renal calculi whose urine must be strained
Rationale:
The nurse is legally responsible for client assignments and must assign tasks on the basis of the
guidelines of the state nursing practice act and the job descriptions set forth by the employing
agency. The nursing assistant has been trained to measure, collect, and strain urine. The nurse
would provide instructions to the nursing assistant regarding the task, but the task is within the
role description of a nursing assistant. A client scheduled for a cardiac stress test requires
preprocedure preparation for the test, which is not a task within the role description for a
nursing assistant. The nursing assistant cannot provide dressing change instructions to a client
who has had a mastectomy. It is not within the role description of the nursing assistant to report
abnormal laboratory values to the health care provider.
Test-Taking Strategy: Note that the question asks for the tasks to be assigned to the nursing
assistant. When asked questions related to delegation, think about the role description of the
employee and the needs of the client. Eliminate the comparable or alike options that are
invasive and require higher level of skill. For the nursing assistant, select the tasks that are
noninvasive and do not require a high skill level, meaning that assessment, teaching, and
monitoring are inappropriate tasks. Review the guidelines related to delegation to a nursing
assistant if you had difficulty with this question.
A nurse is working in an urgent care center during the night shift. A client arrives at the center
for treatment after a sexual assault. The nurse has never cared for anyone who has been raped.
To determine the necessary actions in regard to this client's injury, the nurse should take which
action?
,a. Ask a medical assistant.
b. Call the nurse in charge of the day shift.
c. Ask the police officers who brought the client to the center.
d. Check the unit policy for the protocol for the care of clients who have been sexually assaulted
d. Check the unit policy for the protocol for the care of clients who have been sexually
assaulted.
Rationale:
A policy or procedure is a designated plan or course of action to be taken in a specific situation.
Written copies of all policies are usually placed in a policy manual that is available in each
department or may be available online. Specific unit policies are sometimes referred to as
protocols. The policy or protocol for a client who has been raped will describe the physical,
psychosocial, and legal responsibilities of the nurse. Calling the nurse in charge during the day
shift or asking an medical assistant or the police officers who brought the client into the center
is inappropriate. If the nurse needs additional information after reviewing the policy or protocol,
it would be most appropriate to contact the agency nursing supervisor of the night shift.
Test-Taking Strategy: Use the process of elimination, recalling the legal implications related to
providing care. Note the incorrect comparable or alike options that suggest obtaining
information from other individuals. Review the purpose of organizational policies, procedures,
or protocols if you had difficulty with this question.
A nurse at the long-term care unit on the 11 p.m. to 7 a.m. shift is gathering the nursing staff
together to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has
an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol
intoxication. Which action is most appropriate for the nurse to take?
a. Contact the nursing supervisor.
b. Ask the staff member how much alcohol she has consumed.
c. Tell the staff member that she is not allowed to administer medications.
, d. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off.
a. Contact the nursing supervisor.
Rationale:
When a staff member reports to work in a state of alcohol intoxication, the nurse notes the
signs objectively and asks a second person to validate these observations. The nurse also
contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in
judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated
nurse is removed from the situation. The incident is recorded and the nurse describes the
observations, states the action taken, indicates future plans, and has the staff member sign and
date the memo of the recorded incident. Refusal to sign and date the memo should be noted by
the nurse and a witness. Neither asking the staff member to rest in the nurses' lounge until the
effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to
administer medications removes the staff member from the client care area, jeopardizing client
safety. Asking the staff member how much alcohol she has consumed is confrontational and
irrelevant.
Test-Taking Strategy: Use the process of elimination, keeping in mind that client safety is the
priority. Asking the staff member how much alcohol she has consumed is irrelevant, so
eliminate this option. Next eliminate the comparable or alike options that do not involve
removal of the staff member from the client care area. Review nursing responsibilities when
substance abuse is suspected in a staff member if you had difficulty with this question.
A nurse discovers that another nurse has administered an enema to a client even though the
client told the nurse that he did not want one. Which is the most appropriate action for the
nurse to take?
a. Contact the client's health care provider.
b. Report the incident to the nursing supervisor.
c. Tell the client that the nurse did the right thing in giving the enema.
d. Confront the nurse who gave the enema and tell the nurse that she is going to be charged
with battery.
