HESI Comprehensive Review for the
NCLEX-RN Examination
What types of procedures should be assigned to professional nurses?
correct or
Sterile answers
invasive
procedures.
Negligence is measured by reasonableness. What question might the nurse
ask when
determining such reasonableness? correct answers Would a reasonable
and prudent
nurse act in the same manner under the same
circumstances?
List the 4 elements that are necessary to prove negligence. correct
answers
Failure toDuty.
protect client again unreasonable risk. Breach of duty. Failure
to performto established standards. Causation. A connection exists between
according
conduct
the nurseofand the resulting damage. Damages. Damage is done to the
client, physical
or
mental.
Define an intentional tort and five one example. correct answers
Conduct to
damage causing
another person in a willful or intentional way without just
cause. Example
Hitting a client out of anger, not in a manner of self
protection.
Voluntary admission correct answers Client admits self to an institution for
treatment
and restrains his or her civil rights. He or she may leave at
any time.
Involuntary admission correct answers Someone other than client
applies admission
client's for the to an institution requires certification by 1 or 2 health
care the
that providers
person is a danger to self or
others.
List 5 activities a person who is declared incompetent cannot perform.
correct
Vote, answers
make contracts or wills, drive a care, sue or be sued, hold a
professional license.
Name 3 legal requirements of a surgical permit correct answers Voluntary,
and
informed,
written.
Who may give consent for medical treatment? correct answers Alert,
coherent, or
otherwise competent adults, a parent or legal guardian, a person in loco
parentisorofincompetent
minors
adults.
What law protects the nurse who provides care or gives aid in an emergency
situation?
correct answers The Good Samaritan
Act.
,What action should the nurse take if he or she questions a health care
provider's
prescription that they believe is wrong? correct answers Inform the
health care
provider. Record that the health care provider was informed and the
health careresponse to such information. Inform the nursing supervisor.
provider's
Refuse
out the to carry
prescription.
Describe the nurse's legal responsibility when asked to perform a task for r
which
she is he o
unprepared. correct answers Inform the health care provider or
person
the asking
nurse to perform the task that he or she is unprepared to carry out the
task.
to Refuse
perform the
task.
Describe nursing care of the restrained client. correct answers Apply
restraints
properly. Check restraints frequently to see that they are not causing injury
and record
such monitoring. Remove restraints as soon as possible. Use restraints as a
last resort.
By what authority may RNs delegate nursing care to others? correct
answers State
Nurse Practice
Act
A UAP may perform care that falls within which components of the nursing
process?
correct answers
Implementation
Which type of communication is necessary to implement a democratic
leadership
correct style?Assertive communication
answers
skills
What are the 4 rights of communication? correct answers Right
task, right
circumstance, right person, right direction or communication, and right
supervision.
Which tasks can be delegated to a UAP? A. Inserting a Foley catheter. B.
Measuring
and recording the client's output through a Foley catheter. C. Teaching a
clientfor
care how to
a catheter after discharge. D. Assessing for symptoms of a
urinary tract
infection. correct answers A. is a sterile invasive procedure and
should not to
delegated bea UAP. B. Falls within the implementation phase, does not
involve nursing
judgement. Evaluation of the I & O must be done by the nurse. C.
Client teaching
requires the abilities of a nurse should not be delegated. D.
Assessmentbymust
performed be
the nurse and should not be
delegated.
What are the essential steps of effective supervision? correct answers
Direction,
evaluation, and follow-
up.
Which of the following is an example of assertive communication? A.
You needthe
improve to way you spend your time so that all of your care gets
performed.
noticed thatB. I've of your clients did not get their care today. correct
many
answers
an A. This
aggressive is
communication, which causes anger, hostility, and a
defensive
B. Assertive attitude.
communication begins with I rather than you and clearly
states the
proble
m.
,List the three levels of disaster management correct answers Disaster
preparedness,
disaster response, and disaster
recovery.
List examples of the three levels of prevention in disaster
management.
answers Primary:correct
develop plan, train and educate personnel and public.
Secondary:
triage, treatment shelter, supervision. Tertiary: follow-up, recovery
assistance,
prevention of future
disasters.
Triage correct answers To sort or
categorize
Identify three bio-terrorism agents. correct answers Anthrax,
pneumonic
botulism, plague, inhalation tularemia, viral hemorrhage, fever, ricin,
smallpox,
sarin, radiation.
What Po2 value indicates respiratory failure in adults? correct answers Po2
below 60
mmH
g
What blood value indicates hypercapnia? correct answers Pco2 above
45 mm Hg
Identify the condition that exits when the Po2 is less than 50 mmHg and
Fio2 is
than greater
60%. correct answers
Hypoxemia
List three symptoms of respiratory failure in adults. correct answers
Dyspnea
tachypnea, intercostal and sternal retractions
cyanosis.
List four common causes of respiratory failure in children. correct answers
Congenital
heart disease, infection or sepsis, respiratory distress syndrome,
aspiration,
overload orfluid
dehydration.
What percentage of O2 should a child in severe respiratory distress
receive? correct
answers
100%
Acute Respiratory Distress Syndrome correct answers Is an unexpected,
catastrophic
pulmonary complication occurring a person with no previous
pulmonary
Mortality problem.
rate
50%.
Interventions to prevent complications of clients on mechanical ventilation
with ARDS
correct answers Elevate head of bed at least 30 degrees. Assist with daily
awakening.
Implement a comprehensive oral hygiene program. Implement a
comprehensive
mobilization
program.
Suction correct answers Only when secretions are
present.
Allen Test correct answers Perform prior to drawing ABGs. Ensures
circulation ot the hand if thrombosis of the radial artery should follow
collateral
the puncture.
, Positive Allen test correct answers Make the clients hand blanch by
obliteration
the radial and boththe ulnar pulses. Then release the pressure over the ulnar
artery
flow only. Ifthe ulnar artery is good, flushing will be see
through
immediately.
Negative Allen Test correct answers Repeat on the other arm. If this
test is alsoseek another site for arterial
negative,
puncture.
Cardinal signs of Acute Respiratory Failure in children correct answers
Restlessness,
Tachypnea, Tachycardia, and
Diaphoresis.
pH correct answers 7.35-
7.45
Pco2 correct answers 35-45
mm Hg
HCO3 correct answers 21-28
mEq/L
Po2 correct answers 80-100
mm Hg
O2 Saturation correct answers 95%-
100%
Shock correct answers Widespread, serious reduction of tissue perfusion,
which
to leads
generalized impairment of cellular
function.
What is the most common cause of shock? correct answers
Hypovolemia
What causes septic shock? correct answers Release of endotoxins by
bacteria,
act on nerveswhichin vascular spaces in the periphery, causing vascular
pooling,return,
venous reduced and decreased cardiac output and result in poor systemic
perfusion.
What is the goal of treatment for hypovolemic shock? correct answers Quick
of cardiac output and result in poor systemic
restoration
perfusion.
What intervention is used to restore cardiac output when hypovolemic
shock exists?
correct answers Rapid infusion of volume
expanding fluids
It is important to differentiate between hypovolemic and cardiogenic shock.
Hownurse
the mightdetermine the existence of cardiogenic shock? correct answers
History
with leftofventricular
MI failure or possible cardiomyopathy, with symptoms of
pulmonary
edem
a.
If a client is in cardiogenic shock, what might result from administration
of volume fluids? correct answers Pulmonary
expanding
Edema
What intervention can the nurse expect to perform in the event of such an
correct answers Administer medications to manage preload, contractility
occurrence?
and orFor
load. after-
example to decrease after-load nitroprusside Nipride may be
administered.
