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HESI Fundamentals of Nursing Assessment Exam Questions with Correct Selected Answers Rated, Exams of Nursing

King's College London (KCL)Nursing

HESI Fundamentals of Nursing Assessment Exam Questions with Correct Selected Answers Rated 100%. 1. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified. - A

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HESI Fundamentals of Nursing Assessment Exam
Questions with Correct Selected Answers Rated 100%.
1. The nurse observes a newly admitted older adult female take short steps and
walk very slowly while pushing a walker in front of her. What action should the
nurse take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified. - Answers-
A) Complete a full fall risk assessment of the client.
2. While suctioning a client's nasopharynx, the nurse observes that the client's
oxygen saturation remains at 94%, which is the same reading obtained prior to
starting the procedure. What action should the nurse take in response to this
finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth. - Answers-C)
Complete the intermittent suction of the nasopharynx.
3. An older woman with end stage heart disease is hospitalized for severe heart
failure. She is alert, oriented, and requests that no heroic measures are
implemented if her breathing stops. What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care. - Answers-A) Discuss
with the client her meaning of heroic measures.
4. A client diagnosed with primary open-angle glaucoma received a prescription for
biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse
plan to include in this client's teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops." - Answers-A)
"Do not allow the dropper bottle to touch the eye."
5. When assessing a client who starts to wheeze related data should obtain?
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HESI Fundamentals of Nursing Assessment Exam

Questions with Correct Selected Answers Rated 100%.

  1. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified. - Answers- A) Complete a full fall risk assessment of the client.
  2. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client's nose and mouth. - Answers-C) Complete the intermittent suction of the nasopharynx.
  3. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a "do not resuscitate" (DNR) prescription. C) Set up a family conference to discuss the client's. D) Consult the palliative care team about client's care. - Answers-A) Discuss with the client her meaning of heroic measures.
  4. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client's teaching? A) "Do not allow the dropper bottle to touch the eye." B) "Administer the medication directly on the cornea." C) "Squeeze your eye closed after administering the drops." D) "Wash your hands after each administration of eye drops." - Answers-A) "Do not allow the dropper bottle to touch the eye."
  5. When assessing a client who starts to wheeze related data should obtain?

A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors. - Answers-D) Precipitating factors.

  1. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply. A) Syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. E) Shuffling gait. - Answers-A) Syncope when bending.
  2. B) Hand tremors.
  3. C) Diminished visual acuity.
  4. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client's risk for infection related to the catheter? A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids. C) Administer a PRN antipyretic if a fever develops. D) Secure the drainage bag at bladder level during transport. - Answers-B) Encourage increased intake of oral fluids.
  5. To assess the quality of an adult client's pain, what approach should the nurse use? A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures. - Answers-C) Ask the client to describe the pain.
  6. A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response is best for the nurse to provide? A) "That's correct, you do not have long to live." B) "Would you like me to call your minister?" C) "Don't give up, you still have chemotherapy to try."

C) Raise the head and knee gatch when lying in a supine position. D) Transfer into a wheelchair close to the nurse's station for observation. - Answers-B) Position prone with a small pillow below the diaphragm.

  1. At 0100 on a male client's second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? A) Leave the room and close the door to the client's room. B) Assess the appearance of the client's surgical dressing. C) Bring the client a prescribed PRN sedative-hypnotic. D) Discuss symptoms of sleep deprivation with the client. - Answers-C) Bring the client a prescribed PRN sedative-hypnotic.
  2. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? A) Remove identifying information of the clients who participated. B) Recall that authored content may be legally discoverable. C) Share material from credible, peer reviewed sources only. D) Respect all copyright laws when adding website content. - Answers-A) Remove identifying information of the clients who participated.
  3. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? A) Answer the client's specific questions with a short understandable explanation. B) Postpone the procedure until the client understands the risks and benefits. C) Call the client's next of kin and ask them to provide verbal consent. D) Page the healthcare provider to return and provide additional explanation. - Answers-B) Postpone the procedure until the client understands the risks and benefits.
  4. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? A) Tilt the pelvis forwards and backwards. B) Bend the arm by flexing the ulnar to the humerus. C) Turn the head to the right and left.

D) Extend the arm at the side and rotate in circles. - Answers-B) Bend the arm by flexing the ulnar to the humerus.

  1. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? A) Assess for side effects of the medication. B) Document the client's responses. C) Complete a medication error report. D) Determine if the pain was relieved. - Answers-A) Assess for side effects of the medication.
  2. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? A) Hyperphosphatemia. B) Hypocalcemia. C) Hypermagnesemia. D) Hypokalemia. - Answers-D) Hypokalemia.
  3. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A) Obtain a prescription from the healthcare provider regarding visitation privileges. B) Request a consultation with the ethics committee for resolution of the situation. C) Encourage the client to speak with her husband regarding his disruptive behavior. D) Communicate the client's wishes to all members of the multidisciplinary team. - Answers-B) Request a consultation with the ethics committee for resolution of the situation.
  4. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respiration. What follow-up action should the nurses take first? A) Determine pulse pressure. B) Auscultate heart sounds. C) Measure oxygen saturation.

A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. - Answers-B) Discontinue the use of the nasal cannula.

  1. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client's room to provide family privacy. D) Sit quietly with the family to offer comfort and support. - Answers-C) Close the door to client's room to provide family privacy.
  2. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing. B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. - Answers-C) Replace the gauze with transparent dressing.
  3. What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A) Check capillary refill of toes on lower extremity with Unna's paste boot. B) Apply dressing to wound area before applying the Unna's paste boot. C) Wrap the leg from the knee down towards the foot. D) Remove the Unna's paste boot q8h to assess wound healing. - Answers- A) Check capillary refill of toes on lower extremity with Unna's paste boot.
  4. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A) Check for a blood return. B) Reposition the client's arm. C) Remove the IV site dressing. D) Flush the lock with saline. - Answers-B) Reposition the client's arm.
  1. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A) Sensory pattern, area, intensity, and nature of the pain. B) Trigger points identified by palpation and manual pressure of painful areas. C) Schedule and total dosages of drugs currently used for breakthrough pain. D) Sympathetic responses consistent with onset of acute pain. - Answers-A) Sensory pattern, area, intensity, and nature of the pain.
  2. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? A) Use disposable plates and utensils. B) Stay in a room with the door closed. C) Dispose of soiled dressings in plastic bags that are securely closed. D) Others who are in the same room with the client should wear a mask. - Answers-C) Dispose of soiled dressings in plastic bags that are securely closed.
  3. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? A) Lightly coat the wound with povidone-iodine solution. B) Irrigate the wound with sterile normal saline. C) Flush the wound with sterile hydrogen peroxide. D) Remove the eschar with a wet-to-dry dressing. - Answers-B) Irrigate the wound with sterile normal saline.
  4. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A) Document the client's circadian rhythms. B) Assess for flushed, warm skin regularly. C) Measure temperature at regular intervals. D) Vary sites for temperature measurement. - Answers-C) Measure temperature at regular intervals.

internal pressure (usually form subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is less of a priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).

  1. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse. - Answers-A) Loosen the right wrist restraint.
  2. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression- the restraints.
  3. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. C) Position the client laterally, prone, and dorsally in sequence. D) Gently lift the client when moving into a desired position. - Answers-D) Gently lift the client when moving into a desired position.
  4. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should NOT be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.
  5. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client w/ left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving.

B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot. - Answers-D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.

  1. The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A) Clamp the tube for 20 minutes. B) Flush the tube with water. C) Administer the medications as prescribed. D) Crush the tablets and dissolve in sterile water. - Answers-B) Flush the tube with water.
  2. The NGT should be flushed before, after, and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.
  3. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Contact the healthcare provider and complete a medication variance form. B) Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C) Notify the charge nurse and complete an incident report to explain the missed dose. D) Give the missed dose at 1300 and change the schedule to administer daily at 1300. - Answers-D) Give the missed dose at 1300 and change the schedule to administer daily at 1300.
  4. To ensure that a therapeutic level of medication is maintained, the nurse should administer dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug.
  5. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?

D) Mix all medications together to facilitate administration. - Answers-A) Mix each medication individually.

  1. Medications should be mixed separately (A) to prevent clumping.
  2. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? - Answers-Close-ended questions.
  3. Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use close-ended questions (C) that focus on common signs and symptoms about the client's health problem. (A, B, and D) are used when therapeutically interacting and should be used after specific information is obtained from the client.
  4. The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A) Thalamus. B) Hypothalamus. C) Frontal lobe. D) Parietal lobe. - Answers-C) Frontal lobe.
  5. The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as pituitary. (D) is the location of sensory and motor functions.
  6. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. - Answers-C) Examining a chest x-ray obtained after the tubing was inserted.
  7. Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement
  1. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase. - Answers-C) I will limit my intake of beef to 4 ounces per week.
  2. Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase.
  3. Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - Answers-B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
  4. Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification.
  5. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions.
  1. (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.
  2. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals. - Answers-A) Determine the etiology of the problem.
  3. Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).
  4. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level. - Answers-C) Reposition in a Sim's position with the client's weight on the anterior ilium.
  5. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.
  6. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) Prone. B) Fowler's. C) Sims'. D) Supine. - Answers-B) Fowler's.
  7. The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy

procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration.

  1. A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. - Answers-C) Healthcare provider notified of client's refusal to have blood specimens collected for testing.
  2. When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues.
  3. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors. - Answers-B) Nutritional history.
  4. Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.
  5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr.
  1. A client who has been NPO for 3 days is receiving an infusion of D5W 0. normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV. - Answers-C) Document in the medical record that these normal findings are expected outcomes.
  2. The results are all within normal range.(C). No changes are needed (A, B, and D).
  3. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner. - Answers-B) 8 a.m., 4 p.m., and midnight.
  4. Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).
  5. What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure. - Answers-B) A decreased flow rate could result in the formation of a thrombosis.
  1. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration.
  2. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match. - Answers-D) Ensure the accuracy of the blood type match.
  3. All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.
  4. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment. - Answers-B) Battery
  5. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request.
  6. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's.