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CCRI Nursing 1010 HESI 1 NCLEX Test| Questions solved 100% Correct/Verified Solutions
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CCRI Nursing 1010 HESI 1 NCLEX Test|Questions solved 100% Correct/Verified
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A hospitalized client tells the nurse that an instructional directive is being prepared and that
the lawyer will be bringing the document to the hospital today for witness signatures. The
client asks the nurse for assistance in obtaining a witness to the will. Which is the most
appropriate response to
the client?
1. "I will sign as a witness to your signature."
2. "You will need to find a witness on your own."
3. "Whoever is available at the time will sign as a witness for you."
4. "I will call the nursing supervisor to seek assistance regarding
your request." - ANSWER Answer: 4
Rationale: Instructional directives (living wills) are required to be in writing and
signed by the client. The client's signature must be witnessed by specified
individuals or notarized. Laws and guidelines regarding instructional directives vary
from state to state, and it is the responsibility of the nurse to know the laws. Many
states prohibit any employee, including the nurse of a facility where the client is
receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful
response. The nurse should seek the assistance of the nursing supervisor.
The nurse has made an error in documentation of the dose administered of an opioid pain
medication in the client's record. The nurse draws 1 mg from the vial and another
registered nurse (RN) witnesses wasting of the
,remaining 1 mg. When scanning the medication, the nurse entered into the medication
administration record (MAR) that 2 mg of hydromorphone was administered instead of
the actual dose administered, which was 1 mg. The
nurse should take which action(s) to correct the error in the MAR? Select all that apply.
1. Complete and file an occurrence report.
2. Right-click on the entry and modify it to reflect the
correct information.
3. Document the correct information and end with the
nurse's signature and title.
4. Obtain a cosignature from the RN who witnessed the waste of
the remaining 1 mg.
5. Document in a nurse's note in the client's record detailing
the corrected information. - ANSWER Answer: 2, 3, 4, 5
Rationale: Electronic health records (EHR) will have a time date stamp that
indicates an amendment has been entered. If the nurse makes an error in the
MAR, the nurse should follow agency policies to correct the error. In the MAR, the
nurse can click on the entry (usually right-click) and modify it to reflect the
corrected information. Since this is an opioid medication, the nurse should obtain a
cosignature from the RN who witnessed the wasting of the excess medication, to
validate that 1 mg, rather than 2 mg, was given. A nurse's note should be used to
detail the event and the corrections made, and the nurse's name and title will be stamped
on the entry in the EHR. An occurrence report is not necessary in this
situation.
Which identifies accurate nursing documentation notation(s)? Select all
that apply.
,1. The client slept through the night.
2. Abdominal wound dressing is dry and intact
without drainage.
3. The client seemed angry when awakened for vital sign
measurement.
4. The client appears to become anxious when it is time for
respiratory treatments.
5. The client's left lower medial leg wound is 3 cm in length without redness,
drainage, or edema - ANSWER Answer: 1, 2, 5 Rationale: Factual documentation
contains descriptive, objective information about what the nurse sees, hears, feels,
or smells. The use of inferences without supporting factual data is not acceptable,
because it can be misunderstood. The use of vague terms, such as seemed or
appears, is not acceptable because these words suggest that the nurse is stating an
opinion
A nursing instructor delivers a lecture to nursing students regarding the issue of clients'
rights and asks a nursing student to identify a situation that represents an example of
invasion of client privacy. Which situation, if
identified by the student, indicates an understanding of a violation of this client right?
1. Performing a procedure without consent
2. Threatening to give a client a medication
3. Telling the client that he or she cannot leave the hospital
4. Observing care provided to the client without the client's
permission - ANSWER Answer: 4
Rationale: Invasion of privacy occurs with unreasonable intrusion into an individual's
private affairs. Performing a procedure without consent is an example of battery.
Threatening to give a client a medication constitutes assault. Telling the
, client that the client cannot leave the hospital constitutes false imprisonment.
Nursing staff members are sitting in the lounge taking their morning break.
An assistive personnel (AP) tells the group that she thinks that the unit
secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to
tell the nursing staff that the secretary probably contracted the disease from
her husband, who is supposedly a drug addict. The registered nurse should
inform the AP that making this accusation has violated which legal tort?
1. Libel
2. Slander
3. Assault
4. Negligence - ANSWER Answer: 2
Rationale: Defamation is a false communication or a careless disregard for the
truth that causes damage to someone's reputation, either in writing (libel) or
verbally (slander). An assault occurs when a person puts another person in fear of
a harmful or offensive contact. Negligence involves the actions of professionals
that fall below the standard of care for a specific professional group.
An older woman is brought to the emergency department for treatment of
a fractured arm. On physical assessment, the nurse notes old and new
ecchymotic areas on the client's chest and legs and asks the client how the
bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her son frequently hits her if supper is not prepared on time
when he arrives home from work. Which is the most appropriate nursing
response?
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