1. A 20-year-old female client with a noticeable body odor has refused to shower for the last

• A 20-year-old female client with a noticeable body odor has refused to shower for the last
• days. She states, "I have been told that it is harmful to bathe during my period." Which

action should the nurse take first?

• Accept and document the client's wish to refrain from bathing.
• Offer to give the client a bed bath, avoiding the perineal area.
• Obtain written brochures about menstruation to give to the client.
• Teach the importance of personal hygiene during menstruation with the client.: D

Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

• 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?

• Take a vitamin supplement tablet once a day.
• Change positions in the chair at least every hour.
• Increase daily intake of water or other oral fluids.

D. Purchase a newer model wheelchair.: B

Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

• After a needle stick occurs while removing the cap from a sterile needle, which action

should the nurse implement?

• Complete an incident report.
• Select another sterile needle.
• Disinfect the needle with an alcohol swab.

D. Notify the supervisor of the department immediately.: B

Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. 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

1 1/28

HESI NCLEX RN FUNDAMENTALS QUESTIONS AND

CORRECT ANSWERS 100% SUCCESS GUARANTEED 1 / 2

incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

• 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?

• Provide the client with a list of Internet sites that answer frequently asked questions

about medications.

• Advise the client to obtain a current edition of a drug reference book from a local

bookstore or library.

• Reassure the client that information about the medication is included in the written

instructions.

• Encourage the client to call the clinic nurse or health care provider if any questions

arise.: D

Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options 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.

• 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?

• Ask the client to remain quiet so the procedure can be performed safely.
• Concentrate on completing the insertion as efficiently as possible.
• Calmly reassure the client that the discomfort will be temporary.

D. Tell the client a joke as a means of distraction from the procedure.: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

• 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?

• Maintain standard precautions.
• Initiate contact isolation measures.
• Insert an indwelling urinary catheter.

2 2/28

• / 2