Evolve HESI Fundamentals Practice Questions and Answers 2023

Evolve HESI Fundamentals Practice
Questions and Answers 2022
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take
next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. – Correct Answer: C
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in
place will help locate the meatus when attempting the second catheterization (C). The client should
have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the
location of the catheter unless it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D).
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a
heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to
this client?
A. “Monitoring Your Blood Pressure at Home”
B. “Smoking Cessation as a Lifelong Commitment”
C. “Decreasing Cholesterol Levels Through Diet”
D. “Stress Management for a Healthier You” – Correct Answer: C
A health promotion brochure about decreasing cholesterol (C) is most important to provide this client,
because the most significant risk factor contributing to development of arteriosclerosis is excess dietary
fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of
arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as
important as lowering cholesterol (C).
Ten minutes after signing an operative permit for a fractured hip, an older client states, “The aliens will
be coming to get me soon!” and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client’s neurologic status.

C. Notify the surgeon about the comment.
D. Ask the client’s family to co-sign the operative permit. – Correct Answer: B
This statement may indicate that the client is confused. Informed consent must be provided by a
mentally competent individual, so the nurse should further assess the client’s neurologic status (B) to be
sure that the client understands and can legally provide consent for surgery. (A) does not provide
sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C)
and permission obtained from the next of kin (D).
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent
complications of immobility. Which intervention should be included in this instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client’s fluid intake to prevent diarrhea.
C. Massage the client’s legs to reduce embolism occurrence.
D. Turn the client from side to back every shift. – Correct Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and
D) are all potentially harmful practices that place the immobile client at risk of complications.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he
states, “I feel faint.” Before the nurse can get the client to a chair, the client starts to fall. Which is the
priority action for the nurse to take?
A. Check the client’s carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor. – Correct Answer: D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and
the nurse. Lowering the client to the floor should be done when the client cannot support his own
weight. The client should be placed in a bed or chair only when sufficient help is available to prevent
injury. (A) is important but should be done after the client is in a safe position. Because the client is not
supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other
clients.
A female nurse is assigned to care for a close friend, who says, “I am worried that friends will find out
about my diagnosis.” The nurse tells her friend that legally she must protect a client’s confidentiality.
Which resource describes the nurse’s legal responsibilities?

A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient’s Bill of Rights
D. ANA Standards of Practice – Correct Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality
and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but
does not include legal guidelines. (C and D) describe expectations for nursing practice but do not
address legal implications.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is achieved.
D. Ask the client to describe the routine that the client is currently following. – Correct Answer: D
The nurse should first evaluate whether the client has been adhering to the original instructions (D). A
verbal report of the client’s routine will provide more specific information than the client’s written diary
(B). The nurse can then determine which changes need to be made (A). The routine practiced by the
client is clearly unsuccessful, so encouragement alone is insufficient (C).
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the
sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. – Correct Answer: B
The most important teaching is to change positions frequently (B) because pressure is the most
significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake (A
and C) may also be beneficial promote healing and reduce further risk. (D) is an intervention of last
resort because this will be very expensive for the client.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

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?
Give the missed dose at 1300 and change the schedule to administer daily at 1300.

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?
Give an around-the-clock schedule for administration of analgesics.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?
determine the etiology of the problem

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?
A decreased flow rate could result in the formation of a thrombosis.

The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?
Continue asking the mother questions about the child.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
Assess for bladder distention.

A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs?
Blood transfusions are forbidden.

While instructing a male client’s wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?
Acknowledge that she is supporting the arm correctly.

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?
Fowler’s.

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse’s first response?
It is important that you continue your medication while learning to meditate.

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
150

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?
Frontal lobe

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?
Initiate an alternate site for the IV infusion of the medication.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?
Request and document the name of the certified translator.

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client’s teaching plan?
Place a pillow between your knees while lying in bed to prevent hip dislocation.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first?
Notify the healthcare provider of the family’s request.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?
Nutritional history.

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute?
21

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Instruct the client that the stoma will become smaller when the initial swelling diminishes.

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
1.5ml

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
Examining a chest x-ray obtained after the tubing was inserted.

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
124 gtt/min.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client’s silence?
It is OK if you don’t want to talk about your surgery. I will be available when you are ready.

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?
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?
Avoid any types of sprays, powders, and perfumes.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?
Assist the ambulating client back to the bed.

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
During the inhalation

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?
I will limit my intake of beef to 4 ounces per week.

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?
Loosen the right wrist restraint.

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?
8 a.m., 4 p.m., and midnight.

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump?
180

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?
The nurse who transferred the client to the chair when the fall occurred.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?
The client voluntarily signed the form.

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?
Flush the tube with water.

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide?
Be sure to have a complete physical examination before beginning your planned exercise program.

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the
upper torso

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?
upper arm circumference

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?
Degree of flexion and extension of the client’s knee joint.

A client who is 5′ 5″ tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?
What vitamin and mineral supplements do you take?

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client’s nursing care?
Gently lift the client when moving into a desired position.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?
Acknowledge the client’s distress and tell her it is all right to cry.

Which action is most important for the nurse to implement when donning sterile gloves?
Keep gloved hands above the elbows.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
Skim milk, turkey salad, roll, and vanilla ice cream.

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?
Reposition in a Sim’s position with the client’s weight on the anterior ilium.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with “miseries.” Based on this statement, which focused assessment should the nurse conduct?
Inquire about the source and type of pain

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client’s readiness to manage his wound care after discharge? The client
demonstrates the wound care procedure correctly.

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?
Report the results of the vital signs to the nurse.

The nurse observes an unlicensed assistive personnel (UAP) taking a client’s blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client’s usual range. What action is most important for the nurse to implement?
Reassess the client’s blood pressure using a larger cuff.

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to
1½ tablets

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?
Ensure the accuracy of the blood type match.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?
Hot remedies restore balance after surgery, which is considered a “cold” condition.

A client’s infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding “stronger pain medications.” What initial action is most important for the nurse to take?
Measure the pulse volume and capillary refill distal to the infiltration.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?
Reposition the client on her side

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
A lactating woman nursing her 3-day-old infant.

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly
often follows relocation to new surroundings.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
Observe the appearance of the skin under the ice pack.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?
Commend the client for selecting a high biologic value protein.

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices?
Many complimentary healing practices can be used in conjunction with conventional practices.

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
Fowler’s.

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received?
11,000 units

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?
Chocolate pudding.

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?
Re-oxygenate the client before attempting to suction again.

When evaluating a client’s plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?
Note which actions were not implemented.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
The body’s receptors adapt over time as they are exposed to heat. (D) describes thermal adaptation, which occurs 20-30 minutes after heat application.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?
is disoriented to place and time.

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer?
1.5 tablets

The healthcare provider prescribes 1,000 ml of Ringer’s Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?
83 gtt/min.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?
Encourage additional oral intake of juices and water

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?
Infuse 10 percent dextrose and water at 54 ml/hr.

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client’s intravenous infusion pump?
63 ml/hour.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
Move the chair parallel to the right side of the bed, and stand the client on the right foot.

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?
) Battery

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

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?
Healthcare provider notified of client’s refusal to have blood specimens collected for testing.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client’s findings?
Immediately after the assessments are completed.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband’s brother and his family, which includes the brother-in-law’s children and the widow’s adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client?
…

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met?
Accepts that punishment from God is not related to illness

Acceptance that she is not being punished by God indicates a desired outcome

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client’s heart sounds?
Use the stethoscope bell over the valvular areas of the anterior chest

Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest

A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?
A) Mix each medication individually

Medications should be mixed separately (A) to prevent clumping.

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?
Closed-ended questions

Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (C) that focus on common signs and symptoms about a client’s health problem

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers?
Rashes in the axillary, groin, and skin fold regions

Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 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?
Document in the medical record that these normal findings are expected outcomes

The results are all within normal range.(C) No changes are needed.

What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications?
Insert a Huber-point needle into the port

An implanted infusion port needs to be accessed using a Huber-point needle (B) (non-coring) to be prevent damage to the self-sealing septum of the port.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take?
Listen and show interest as the client expresses these feelings

When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?
Client

A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client’s health history, but other details, such as subjective data, can only be provided directly from the client.

The nurse is using a genogram while conducting a client’s health assessment and past medical history. What information should the genogram provide?
Genetic and familial health disorders

A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client’s chronic health problems

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction.
Answer: C
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D).

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?
A. “Monitoring Your Blood Pressure at Home”
B. “Smoking Cessation as a Lifelong Commitment”
C. “Decreasing Cholesterol Levels Through Diet”
D. “Stress Management for a Healthier You”
Answer: C
A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol (C).

Ten minutes after signing an operative permit for a fractured hip, an older client states, “The aliens will be coming to get me soon!” and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client’s neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client’s family to co-sign the operative permit.
Answer: B
This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client’s neurologic status (B) to be sure that the client understands and can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D).

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client’s fluid intake to prevent diarrhea.
C. Massage the client’s legs to reduce embolism occurrence.
D. Turn the client from side to back every shift.
Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and D) are all potentially harmful practices that place the immobile client at risk of complications.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, “I feel faint.” Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take?
A. Check the client’s carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor.
Answer: D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. (A) is important but should be done after the client is in a safe position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other clients.

A female nurse is assigned to care for a close friend, who says, “I am worried that friends will find out about my diagnosis.” The nurse tells her friend that legally she must protect a client’s confidentiality. Which resource describes the nurse’s legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient’s Bill of Rights
D. ANA Standards of Practice
Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is achieved.
D. Ask the client to describe the routine that the client is currently following.
Answer: D
The nurse should first evaluate whether the client has been adhering to the original instructions (D). A verbal report of the client’s routine will provide more specific information than the client’s written diary (B). The nurse can then determine which changes need to be made (A). The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient (C).

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.
Answer: B
The most important teaching is to change positions frequently (B) because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake (A and C) may also be beneficial promote healing and reduce further risk. (D) is an intervention of last resort because this will be very expensive for the client.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?
A. Securely grasp the client’s arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client’s bed slowly.
Answer: B
Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed (B). (A) can cause client injury to the skin or joint. (C and D) are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend’s advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens’ adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics.
Answer: C
Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as cranberry juice (C) in preventing UTIs.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level
Answer: A
Long-term protein deficiency is required to cause significantly lowered serum albumin levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein malnutrition.

The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client’s risk of infection?
A. Administration of plasma expanders
B. Use of careful hand washing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Answer: B
Careful hand washing technique (B) is the single most effective intervention for the prevention of contamination to all clients. (A) reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. (C and D) are recommended by various burn centers as possible ways to reduce the chance of infection. (B) is a proven technique to prevent infection.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?
A. White blood cell count
B. Albumin
C. Calcium
D. Sodium
Answer: D
Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically associated with prolonged NG suctioning.

In completing a client’s preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
A. Witness the client’s signature to the permit.
B. Answer the client’s questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Answer: C
The surgeon should be informed immediately that the permit is not signed (C). It is the surgeon’s responsibility to explain the procedure to the cliesxnt and obtain the client’s signature on the permit. Although the nurse can witness an operative permit (A), the procedure must first be explained by the health care provider or surgeon, including answering the client’s questions (B). The client’s questions should be addressed before the permit is signed (D).

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client’s ability to perform a dressing change at home?
A. Determine how the client feels about changing the dressing.
B. Ask the client to describe the procedure in writing.
C. Seek a family member’s evaluation of the client’s ability to change the dressing.
D. Observe the client change the dressing unassisted.
Answer: D
Observing the client directly (D) will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will not provide an opportunity to evaluate the client’s ability to perform the procedure. (B) may be threatening to an older client and will not determine his ability. (C) is not as effective as direct observation by the nurse.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the health care provider and request a prescription for a large-volume enema.
C. Assess the client’s medical record to determine the client’s normal bowel pattern.
D. Instruct the caregiver to increase the client’s fluids to five 8-ounce glasses per day.
Answer: C
This client may not routinely have a daily bowel movement, so the nurse should first assess this client’s normal bowel habits before attempting any intervention (C). (A, B, or D) may then be implemented, if warranted.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client?
A. Steak, baked beans, and a salad
B. Broiled fish, green beans, and an apple
C. Pork chops, macaroni and cheese, and grapes
D. Avocado salad, milk, and angel food cake
Answer: B
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are contraindicated for this client.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child’s age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised.
Answer: C
The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria (C). The child’s cognitive development may not be at the level at which (A) would be effective. Perineal care needs to be provided daily regardless of the client’s age (B). (D) is not indicated and may be perceived as intrusive.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?
A. Review the chart for a signed consent for hospitalization.
B. Get the health care provider’s permission to give the medication.
C. Do not give the medication and document the reason.
D. Complete an incident report and notify the parents.
Answer: C
The nurse should not give the medication and should document the reason (C) because the client is a minor and needs a guardian’s permission to receive medications. Permission to give medications is not granted by a signed hospital consent (A) or a health care provider’s permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary unless the medication had previously been administered.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?
A. Pulse characteristics
B. Open airway
C. Entrance and exit wounds
D. Cervical spine injury
Answer: A
Lightning is a jolt of electrical current and can produce a “natural” defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should occur after assessing for adequate circulation.

The mental health nurse plans to discuss a client’s depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
A.

Only refer to the client by gender.
B.

Identify the client only by age.
C.

Avoid using the client’s name.
D.

Discuss the client another time.
Answer: D
The best nursing action is to discuss the client another time (D). Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender (A) or age (B), and even when not using the client’s name (C).

The nurse is assessing several clients prior to surgery. Which factor in a client’s history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months
Answer: B
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills (A) may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with (C or D) is at less of a surgical risk than (B).

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair.
B. With the nurse’s feet spread apart and knees aligned with the client’s knees, stand and pivot the client into the chair.
C. Assist the client to a standing position by gently lifting upward, underneath the axillae.
D. Stand beside the client, place the client’s arms around the nurse’s neck, and gently move the client to the chair.
Answer: B
(B) describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client’s knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed (A). Clients should never be lifted under the axillae (C); this could damage nerves and strain the nurse’s back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse’s neck (D); this places undue stress on the nurse’s neck and back and increases the risk for a fall.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?
A. “Fill your lungs with air through your mouth and then compress the inhaler.”
B. “Compress the inhaler while slowly breathing in through your mouth.”
C. “Compress the inhaler while inhaling quickly through your nose.”
D. “Exhale completely after compressing the inhaler and then inhale.”
Answer: B
The medication should be inhaled through the mouth simultaneously with compression of the inhaler (B). This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow for deep lung penetration.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
B. Sit quietly in the client’s room until the client leaves the bathroom.
C. Allow the client to cry alone and leave the client in the bathroom.
D. Talk to the client and attempt to find out why the client is crying.
Answer: D
The nurse’s first concern should be for the client’s safety, so an immediate assessment of the client’s situation is needed (D). (A) is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully (B). Although (C) may be correct, the nurse should determine if the client’s safety is compromised and offer assistance, even if it is refused.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
Answer: A, B
The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?
A. Document that the client responds to painful stimulus.
B. Observe the client’s response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider.
Answer: A
The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.

A hospitalized client has had difficulty falling asleep for 2 nights and is becoming irritable and restless. Which action by the nurse is best?
A. Determine the client’s usual bedtime routine and include these rituals in the plan of care as safety allows.
B. Instruct the UAP not to wake the client under any circumstances during the night.
C. Place a “Do Not Disturb” sign on the door and change assessments from every 4 to every 8 hours.
D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
Answer: A
Including habitual rituals that do not interfere with the client’s care or safety may allow the client to go to sleep faster and increase the quality of care (A). (B, C, and D) decrease the client’s standard of care and compromise safety.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?
A. “How will this affect your present sexual activity?”
B. “How active is your current sex life?”
C. “How has your sex life changed as you have become older?”
D. “Tell me about your sexual needs as an older adult.”
Answer: A
(A) offers an open-ended question most relevant to the client’s statement. (B) does not offer the client the opportunity to express concerns. (C and D) are even less relevant to the client’s statement.

The health care provider has changed a client’s prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?
A. The client will experience increased tolerance to the drug’s effects and may need a higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C. The medication will be more highly protein-bound, increasing the duration of action.
D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
Answer: B
Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect (B). Drug tolerance (A), protein binding (C), and the drug’s therapeutic index (D) are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?
A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime so the pill can help him sleep.
C. Attend to an acutely ill client’s needs first because this client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control.
Answer: A
Obtaining a subjective estimate of the pain experience by asking the client to rate his pain (A) helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication (B). (C) is judgmental. (D) should be used as an adjunct to pain medication, not instead of medication.

The nurse determines that a postoperative client’s respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
A. Encourage the client to increase ambulation in the room.
B. Offer the client a high-carbohydrate snack for energy.
C. Force fluids to thin the client’s pulmonary secretions.
D. Determine if pain is causing the client’s tachypnea.
Answer: D
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea (increased respiratory rate). Encouraging (A) when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. (B) can increase the client’s carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. (C) could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, “I have been told that it is harmful to bathe during my period.” Which action should the nurse take first?
A. Accept and document the client’s wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first (D), respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose (A or B). Brochures reinforce the teaching (C).

Based on the nursing diagnosis of Risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers.
Answer: A
The best action to decrease the risk of infection in vulnerable clients is hand washing (A). (B) is not necessary unless the client has an infection. (C) increases the risk of infection. (D) does not reduce the risk of infection.

The nurse is counting a client’s respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28
Answer: B
The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled (B). (A, C, and D) are inaccurate recordings.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.)
A. Place the client in a high Fowler’s position.
B. Help the patient assume a left side-lying position.
C. Measure the tube from the tip of the nose to the umbilicus.
D. Instruct the client to swallow after the tube has passed the pharynx.
E. Assist the client in extending the neck back so the tube may enter the larynx.
Answer: A, D
(A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?
A. Reassure the client that many obese people have concerns about sex.
B. Remind the client that sexual relationships need not be affected by obesity.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns.
Answer: D
(D) provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. (A and B) may not be related to her current concern, assume that obesity is the problem, and are communication blocks. (C) may be appropriate after discussing the concerns she is having.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled “opened” and dated 48 hours prior to the current date. Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline solution.
C. Use the saline solution and then relabel the bottle with the current date.
D. Discard the saline solution and obtain a new unopened bottle.
Answer: D
Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded (D). (A, B, and C) describe incorrect procedures.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?
A. Standing on his wife’s strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed.
B. Standing on his wife’s weak side, the caregiver provides security by holding the gait belt from the back.
C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.
Answer: B
His wife is most likely to lean toward the weak side and needs extra support on that side and from the back (B) to prevent falling. (A, C, and D) provide less security for her.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill.
Answer: A
Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will contribute to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken to void.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection
Answer: D
Indwelling urinary catheters are a major source of infection (D). (A and B) are both problems that may require an indwelling catheter. (C) is not affected by an indwelling catheter.

When taking a client’s blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
A. Deflate the cuff completely and immediately reattempt the reading.
B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Answer: C
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. (A) could result in a falsely high reading. (B) reduces circulation, causes pain, and could alter the reading. (D) is not an accurate method of assessing blood pressure.

A client’s blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse.
B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort.
D. Compare the current reading with the client’s previously documented blood pressure readings.
Answer: D
Comparing this reading with previous readings (D) will provide information about what is normal for this client; this action should be taken first. (A) might unnecessarily alarm the client. (B) is premature. Further assessment is needed to determine if the reading is abnormal for this client. (C) could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?
A. The Patient’s Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B. The lawsuit may be settled out of court, but the nurse’s license is likely to be revoked.
C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.
D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Answer: C
The Good Samaritan Act (C) protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient’s Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act (A). The state Board of Nursing has no reason to revoke a registered nurse’s license (B) unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown (D).

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, “I want to go outside now and smoke. It takes forever to get anything done here!” Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff.
D. Review the schedule of outdoor breaks with the client.
Answer: D
The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement?
A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions.
B. Because the client is mentally incompetent, the son has the right to waive informed consent for her.
C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
Answer: A
Although all these measures are important, (A) is most important because it helps ensure client safety. (B) is necessary but does not have the priority of (A). (C and D) are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

The nurse selects the best site for insertion of an IV catheter in the client’s right arm. Which documentation should the nurse use to identify placement of the IV access?
A. Left brachial vein
B. Right cephalic vein
C. Dorsal side of the right wrist
D. Right upper extremity
Answer: B
The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation (B). The basilic vein of the arm is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access.

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
A. “At home I take my pills at 8:00 am.”
B. “It costs a lot of money to buy all of these pills.”
C. “I get so tired of taking pills every day.”
D. “This is a new pill I have never taken before.”
Answer: D
The client’s recognition of a “new” pill requires further assessment (D) to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained (A). Although comments about cost (B) should be considered when developing a discharge plan, (D) is a higher priority. The client’s feelings (C) should be acknowledged, but observation of the five rights of medication administration is most essential.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
A. Perform cough and deep breathing exercises hourly.
B. Turn from side to side in bed at least every 2 hours.
C. Dorsiflex and plantarflex the feet 10 times each hour.
D. Drink approximately 4 ounces of water every hour.
Answer: C
To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion (C). (A, B, and D) are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than (C).

Which action should the nurse implement when providing wound care instructions to a client who does not speak English?
A. Ask an interpreter to provide wound care instructions.
B. Speak directly to the client, with an interpreter translating.
C. Request the accompanying family member to translate.
D. Instruct a bilingual employee to read the instructions.
Answer: B
Wound care instructions should be given directly to the client by the nurse with an interpreter (B) who is trained to provide accurate and objective translation in the client’s primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching (A). Family members should not be used to translate instructions (C) because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter (D) to ensure that the nurse’s instructions are understood accurately by the client.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
A. Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client’s bladder to determine if the client needs to urinate.
Answer: A
Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client’s safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, “I think I will plan a big party for all my friends.” How should the nurse respond?
A. “You may not have enough energy before long to hold a big party.”
B. “Do you mean to say that you want to plan your funeral and wake?”
C. “Planning a party and thinking about all your friends sounds like fun.”
D. “You should be thinking about spending your last days with your family.”
Answer: C
Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as long as the nurse does not perpetuate a client’s denial. (A) is a negative response, implying that the client should not plan a party. (B) puts words in the client’s mouth that may not be accurate. The nurse should support the client’s goals rather than telling the client how to spend her time (D).

The nurse observes a UAP taking a client’s blood pressure in the lower extremity. Which observation of this procedure requires the nurse’s intervention?
A. The cuff wraps around the girth of the leg.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C. The client is placed in a prone position.
D. The systolic reading is 20 mm Hg higher than the blood pressure in the client’s arm.
Answer: B
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit
Answer: A
The contaminated gloves serve as the mode of transmission (A) from the portal of exit (D) of the reservoir (C) to a portal of entry (B).

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?
A. Apply a warm compress proximal to the site.
B. Check for kinks in the tubing and raise the IV pole.
C. Adjust the tape that stabilizes the needle.
D. Flush with normal saline and recount the drop rate.
Answer: B
The nurse should first check the tubing and height of the bag on the IV pole (B), which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous access with normal saline (D), but less invasive actions should be implemented first.

Which client is most likely to be at risk for spiritual distress?
A. Roman Catholic woman considering an abortion
B. Jewish man considering hospice care for his wife
C. Seventh-Day Adventist who needs a blood transfusion
D. Muslim man who needs a total knee replacement
Answer: A
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith (B). Jehovah’s Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?
A. Instruct in the use of the incentive spirometer.
B. Elevate the head of the bed during all meals.
C. Use aseptic technique to change the dressing.
D. Encourage frequent ambulation in the hallway.
Answer: D
Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation (D) in the hallway. (A) helps promote alveolar expansion, reducing the risk for atelectasis. (B) reduces the risk for aspiration. (C) reduces the risk for postoperative infection.

In taking a client’s history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
A. Daily black, sticky stool
B. Daily dark brown stool
C. Firm brown stool every other day
D. Soft light brown stool twice a day
Answer: A
Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly (A). (C) indicates constipation, which is a lesser priority. (B and D) are variations of normal.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
A. Check the bath water temperature.
B. Shut the bathroom door.
C. Ensure that the client has voided.
D. Provide extra towels.
Answer: A
To prevent burns or excessive chilling, the nurse must check the bath water temperature (A). (B, C, and D) promote comfort and privacy and are important interventions but are of less priority than promoting safety.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure.
Answer: C
The nurse should respond with a calm demeanor (C) to help reduce the client’s apprehension. After responding calmly to the client’s apprehension, the nurse may implement (A, B, or D) to ensure safe completion of the procedure.

Which nonverbal action should the nurse implement to demonstrate active listening?
A. Sit facing the client.
B. Cross arms and legs.
C. Avoid eye contact.
D. Lean back in the chair.
Answer: A
Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client (A), which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not (B), and leaning toward the client, not (D). To communicate involvement and willingness to listen to the client, eye contact should be established and maintained (C).

A seriously ill female client tells the nurse, “I am so tired and in so much pain! Please help me to die.” Which is the best response for the nurse to provide?
A. Administer the prescribed maximum dose of pain medication.
B. Talk with the client about her feelings related to her own death.
C. Collaborate with the health care provider about initiating antidepressant therapy.
D. Refer the client to the ethics committee of her local health care facility.
Answer: B
The nurse should first assess the client’s feelings about her death and determine the extent to which this statement expresses her true feelings (B). The client may need additional pain management, but further assessment is needed before implementing (A). (C and D) are both premature interventions and should not be implemented until further assessment is obtained.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit’s nursing guidelines?
A. Americans with Disability Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA’s Scope and Standards of Nursing Practice
D. Patient’s Bill of Rights of 1990
Answer: C
The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to direct the philosophy and standards of psychiatric nursing practice. (A and D) define the client’s rights. (B) provides ethical guidelines for nursing.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
A. Encourage the client to see the clinic’s grief counselor.
B. Determine if the client has a family history of suicide attempts.
C. Inquire about whether the life partner was suffering from AIDS.
D. Consult with the health care provider about the client’s need for antidepressant medications.
Answer: A
The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client’s risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked questions about medications.
B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
C. Reassure the client that information about the medication is included in the written instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
Answer: D
To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider (D) if any questions arise. (A, B, and C) may all include useful information, but these sources of information cannot evaluate the nature of the client’s questions and the follow-up needed.

The nurse is preparing to administer 10 mL of liquid potassium chloride (Kay Ciel) through a feeding tube, followed by 10 mL of liquid acetaminophen (Tylenol). Which action should the nurse include in this procedure?
A. Dilute each of the medications with sterile water prior to administration.
B. Mix the medications in one syringe before opening the feeding tube.
C. Administer water between the doses of the two liquid medications.
D. Withdraw any fluid from the tube before instilling each medication.
Answer: C
Water should be instilled into the feeding tube between administering the two medications (C) to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted (A) when administered via a feeding tube and should be administered separately (B), with water instilled between each medication (D).

When emptying 350 mL of pale yellow urine from a client’s urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
A. Record the amount on the client’s fluid output record.
B. Encourage the client to increase oral fluid intake.
C. Notify the health care provider of the findings.
D. Palpate the client’s bladder for distention.
Answer: A
The amount and appearance of the client’s urine output is within normal limits, so the nurse should record the output (A), but no additional action is needed (B, C, and D).

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?
A. Consult with the pharmacist about the need to continue the medication.
B. Administer the antihypertensive medication as prescribed preoperatively.
C. Withhold the medication until the client is fully alert and vital signs are stable.
D. Contact the health care provider to renew the prescription for the medication.
Answer: D
Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions (D). The pharmacist (A) does not prescribe medications or renew prescriptions. The nurse must have a current prescriptions before administering any medications (B and C).

After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C. Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately.
Answer: B
After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person’s body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device.
Answer: D
The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B) before instilling the medications (C). To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?
A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
B. Remind the client to walk carefully down the stairs until reaching a lower floor.
C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
Answer: B
During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used during a fire and fire doors should be kept closed (D) to help contain the fire.

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she “can’t handle” the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client’s right to informed consent?
A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions.
B. Because the client is mentally incompetent, the son has the right to waive informed consent for her.
C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege.
D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
Answer: D
Health care providers may be found guilty of negligence (D), specifically assault and battery, if they carry out a treatment without the client’s consent. The client’s condition is stable, so (A) is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent (B). Although (C) may have been upheld in the past, when paternalistic medical practice was common, today’s courts are unlikely to accept it.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother’s report?
A. The occurrence of any episodes of sleep apnea
B. The child’s blood pressure, pulse, and respirations
C. Length of rapid eye movement (REM) sleep that the child is experiencing
D. Description of the family’s home environment
Answer: D
School-age children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse cannot determine (C).

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client’s skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?
A. “I know you are capable of giving yourself the insulin.”
B. “Giving yourself the injection seems to make you nervous.”
C. “When I watched you give yourself the injection, you did it correctly.”
D. “Tell me what you want me to do to help you give yourself the injection at home.”
Answer: C
The nurse needs to focus on the client’s positive behaviors, so focusing on the client’s demonstrated ability to self-administer the injection (C) is likely to reinforce his level of competence without sounding punitive. (A) does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. (B) uses reflective dialogue to assess the client’s feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. (D) reinforces the client’s dependence on the nurse.