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HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN EXAM 2024
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HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RN EXAM 2024
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HESI COMPREHENSIVE REVIEW FOR THE NCLEX-RNEXAM
What types of procedures should be assigned to professional nurses? - Answers -
Sterile or invasive procedures.
Negligence is measured by reasonableness. What question might the nurse ask when
determining such reasonableness? - 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. - Answers - Duty. Failure to
protect client again unreasonable risk. Breach of duty. Failure to perform according to
established standards. Causation. A connection exists between conduct of the nurse
and the resulting damage. Damages. Damage is done to the client, physical or mental.
Define an intentional tort and five one example. - Answers - Conduct causing damage to
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 - 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 - Answers - Someone other than client applies for the client's
admission to an institution requires certification by 1 or 2 health care providers that the
person is a danger to self or others.
Describe nursing care of the restrained client. - 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? - Answers - State Nurse
Practice Act
A UAP may perform care that falls within which components of the nursing process? -
Answers - Implementation
Which type of communication is necessary to implement a democratic leadership style?
- Answers - Assertive communication skills
What are the 4 rights of communication? - 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 client how to
care for a catheter after discharge. D. Assessing for symptoms of a urinary tract
infection. - Answers - A. is a sterile invasive procedure and should not be delegated to a
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. Assessment must be performed by the
nurse and should not be delegated.
What are the essential steps of effective supervision? - Answers - Direction, evaluation,
and follow-up.
Which of the following is an example of assertive communication? A. You need to
improve the way you spend your time so that all of your care gets performed. B. I've
noticed that many of your clients did not get their care today. - Answers - A. This is an
aggressive communication, which causes anger, hostility, and a defensive attitude. B.
Assertive communication begins with I rather than you and clearly states the problem.
List the three levels of disaster management - Answers - Disaster preparedness,
disaster response, and disaster recovery.
List 5 activities a person who is declared incompetent cannot perform. - Answers - Vote,
make contracts or wills, drive a care, sue or be sued, hold a professional license.
Name 3 legal requirements of a surgical permit - Answers - Voluntary, informed, and
written.
Who may give consent for medical treatment? - Answers - Alert, coherent, or otherwise
competent adults, a parent or legal guardian, a person in loco parentis of minors or
incompetent adults.
What law protects the nurse who provides care or gives aid in an emergency situation?
- 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? - Answers - Inform the health care provider.
Record that the health care provider was informed and the health care provider's
response to such information. Inform the nursing supervisor. Refuse to carry out the
prescription.
Describe the nurse's legal responsibility when asked to perform a task for which he or
she is unprepared. - Answers - Inform the health care provider or person asking the
nurse to perform the task that he or she is unprepared to carry out the task. Refuse to
perform the task.
,List examples of the three levels of prevention in disaster management. - Answers -
Primary: develop plan, train and educate personnel and public. Secondary: triage,
treatment shelter, supervision. Tertiary: follow-up, recovery assistance, prevention of
future disasters.
Triage - Answers - To sort or categorize
Identify three bio-terrorism agents. - Answers - Anthrax, pneumonic plague, botulism,
smallpox, inhalation tularemia, viral hemorrhage, fever, ricin, sarin, radiation.
What Po2 value indicates respiratory failure in adults? - Answers - Po2 below 60 mmHg
What blood value indicates hypercapnia? - Answers - Pco2 above 45 mm Hg
Identify the condition that exits when the Po2 is less than 50 mmHg and Fio2 is greater
than 60%. - Answers - Hypoxemia
List three symptoms of respiratory failure in adults. - Answers - Dyspnea tachypnea,
intercostal and sternal retractions cyanosis.
List four common causes of respiratory failure in children. - Answers - Congenital heart
disease, infection or sepsis, respiratory distress syndrome, aspiration, fluid overload or
dehydration.
What percentage of O2 should a child in severe respiratory distress receive? - Answers
- 100%
Acute Respiratory Distress Syndrome - Answers - Is an unexpected, catastrophic
pulmonary complication occurring a person with no previous pulmonary problem.
Mortality rate 50%.
Interventions to prevent complications of clients on mechanical ventilation with ARDS -
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 - Answers - Only when secretions are present.
Allen Test - Answers - Perform prior to drawing ABGs. Ensures collateral circulation ot
the hand if thrombosis of the radial artery should follow the puncture.
Positive Allen test - Answers - Make the clients hand blanch by obliteration both the
radial and the ulnar pulses. Then release the pressure over the ulnar artery only. If flow
through the ulnar artery is good, flushing will be see immediately.
, Negative Allen Test - Answers - Repeat on the other arm. If this test is also negative,
seek another site for arterial puncture.
Cardinal signs of Acute Respiratory Failure in children - Answers - Restlessness,
Tachypnea, Tachycardia, and Diaphoresis.
pH - Answers - 7.35-7.45
Pco2 - Answers - 35-45 mm Hg
HCO3 - Answers - 21-28 mEq/L
Po2 - Answers - 80-100 mm Hg
O2 Saturation - Answers - 95%-100%
Shock - Answers - Widespread, serious reduction of tissue perfusion, which leads to
generalized impairment of cellular function.
What is the most common cause of shock? - Answers - Hypovolemia
What causes septic shock? - Answers - Release of endotoxins by bacteria, which act on
nerves in vascular spaces in the periphery, causing vascular pooling, reduced venous
return, and decreased cardiac output and result in poor systemic perfusion.
What is the goal of treatment for hypovolemic shock? - Answers - Quick restoration of
cardiac output and result in poor systemic perfusion.
What intervention is used to restore cardiac output when hypovolemic shock exists? -
Answers - Rapid infusion of volume expanding fluids
It is important to differentiate between hypovolemic and cardiogenic shock. How might
the nurse determine the existence of cardiogenic shock? - Answers - History of MI with
left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary edema.
If a client is in cardiogenic shock, what might result from administration of volume
expanding fluids? - Answers - Pulmonary Edema
What intervention can the nurse expect to perform in the event of such an occurrence? -
Answers - Administer medications to manage preload, contractility and or after-load. For
example to decrease after-load nitroprusside Nipride may be administered.
List 5 assessment findings that occur in most shock victims. - Answers - Tachycardia,
tachypnea, hypotension, cool clammy skin, decrease in urinary output.
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