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HESI Fundamentals Assignment Quiz (1
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- NR 667 VISE
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- NR 667 VISE
HESI Fundamentals Assignment Quiz (1
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HESI Fundamentals Assignment QuizA female client who has breast cancer with metastasis to the liver and spine is admitted with
constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline
(Elavil) for pain control at home. During the admission assessment, which information is most
important for the nurse to obtain?
A. Sensory pattern, area, intensity, and nature of the pain.
B. Trigger points identified by palpation and manual pressure of painful areas.
C. Schedule and total dosages of drugs currently used for breakthrough pain.
D. Sympathetic responses consistent with onset of acute pain. - ANS-A. Sensory pattern, area,
intensity, and nature of the pain.
A client is demonstrating a positive Chvostek's sign. What action should the nurse take?
A. Observe the client's pupil size and response to light.
B. Ask the client about numbness or tingling in the hands.
C. Assess the client's serum potassium level.
D. Restrict dietary intake of calcium-rich foods. - ANS-B. Ask the client about numbness or
tingling in the hands.
Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results. - ANS-D. Ineffective
coping related to response to positive biopsy test results.
What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client outcomes. - ANS-D.
Examine the effectiveness of nursing interventions toward meeting client outcomes.
Before administering a client's medication, the nurse assesses a change in the client's condition
and decides to withhold the medication until consulting with the healthcare provider. After
consultation with the healthcare provider, the dose of the medication is changed and the nurse
administers the newly prescribed dose an hour later than the originally scheduled time. What
action should the nurse implement in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
, D. Discard the original medication administration record. - ANS-C. Document the events that
occurred in the nurses' notes
A female nurse who sometimes tries to save time by putting medications in her uniform pocket
to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet
in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?
A. Accused of diversion.
B. Reported for stealing.
C. Reported for a HIPAA violation.
D. Accused of unprofessional conduct. - ANS-A. Accused of diversion.
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A. Help the client to accept the final stage of life.
B. Assist and support the client in establishing short-term goals.
C. Encourage the client to make future plans, even if they are unrealistic.
D. Instruct the client's family to focus on positive aspects of the client's life. - ANS-B. Assist and
support the client in establishing short-term goals.
A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the
procedure, the nurse observes the healthcare provider contaminate a sterile glove and the
sterile field. What is the best action for the nurse to implement?
A. Report the healthcare provider for the violation in aseptic technique.
B. Allow the completion of the procedure.
C. Ask if the glove and sterile field are contaminated.
D. Identify the break in surgical asepsis and provide another set of sterile supplies. - ANS-D.
Identify the break in surgical asepsis and provide another set of sterile supplies.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
What action should the nurse take after applying gloves?
A. Empty the client's urinary drainage bag.
B. Draw up the irrigating solution into the syringe.
C. Secure the client's catheter to the drainage tubing.
D. Use aseptic technique to instill the irrigating solution. - ANS-B. Draw up the irrigating solution
into the syringe.
Which client assessment data is most important for the nurse to consider before ambulating a
postoperative client?
A. Respiratory rate.
B. Wound location.
C. Pedal pulses.
D. Pain rating. - ANS-A. Respiratory rate.
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