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CCRI NURSING 1010 HESI 1 NCLEX QUESTIONS WITH COMPLETE ANSWERS.
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CCRI NURSING 1010 HESI 1 NCLEX QUESTIONS WITH COMPLETE ANSWERS.
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CCRI NURSING 1010 HESI 1 NCLEXQUESTIONS WITH COMPLETE
ANSWERS
The nnnurse nnhears nna nnclient nncalling nnout nnfor nnhelp, nnhurries nndown nnthe nnhallway
nnto nnthe nnclient's nnroom, nnand nnfinds nnthe nnclient nnlying nnon nnthe nnfloor. nnThe
nnnurse nnperforms nnan nnassessment, nnassists nnthe nnclient nnback nnto nnbed, nnnotifies
nnthe nnprimary nnhealth nncare nnprovider, nnand nncompletes nnan nnoccurrence nnreport.
nnWhich nnstatement nnshould nnthe nnnurse nndocument nnon nnthe nnoccurrence nnreport?
1. nnThe nnclient nnfell nnout nnof nnbed.
2. nnThe nnclient nnclimbed nnover nnthe nnside nnrails.
3. nnThe nnclient nnwas nnfound nnlying nnon nnthe nnfloor.
4. nnThe nnclient nnbecame nnrestless nnand nntried nnto nnget nnout nnof nnbed. nn- nnAnswer
nn16. nnAnswer: nn3
Rationale: nnThe nnoccurrence nnreport nnshould nncontain nna nnfactual nndescription nnof
nnthe
occurrence, nnany nninjuries nnexperienced nnby nnthose nninvolved, nnand nnthe nnoutcome
nnof nnthe
situation. nnThe nncorrect nnoption nnis nnthe nnonly nnone nnthat nndescribes nnthe nnfacts nnas
nnobserved nnby
the nnnurse. nnOptions nn1, nn2, nnand nn4 nnare nninterpretations nnof nnthe nnsituation nnand
nnare nnnot nnfactual
information nnas nnobserved nnby nnthe nnnurse.
A nnclient nnis nnbrought nnto nnthe nnemergency nndepartment nnby nnemergency nnmedical
nnservices nn(EMS) nnafter nnbeing nnhit nnby nna nncar. nnThe nnname nnof nnthe nnclient nnis
nnunknown, nnand nnthe nnclient nnhas nnsustained nna nnsevere nnhead nninjury nnand
nnmultiple nnfractures nnand nnis nnunconscious. nnAn nnemergency nncraniotomy nnis
nnrequired. nnRegarding nninformed nnconsent nnfor nnthe nnsurgical nnprocedure, nnwhich
nnis nnthe nnbest nnaction?
1. nnObtain nna nncourt nnorder nnfor nnthe nnsurgical nnprocedure.
2. nnAsk nnthe nnEMS nnteam nnto nnsign nnthe nninformed nnconsent.
3. nnTransport nnthe nnvictim nnto nnthe nnoperating nnroom nnfor nnsurgery.
,4. nnCall nnthe nnpolice nnto nnidentify nnthe nnclient nnand nnlocate nnthe nnfamily. nn- nnAnswer
nn17. nnAnswer: nn3
Rationale: nnIn nngeneral, nnthere nnare nntwo nnsituations nnin nnwhich nninformed nnconsent
nnof nnan
adult nnclient nnis nnnot nnneeded. nnOne nnis nnwhen nnan nnemergency nnis nnpresent nnand
nndelaying
treatment nnfor nnthe nnpurpose nnof nnobtaining nninformed nnconsent nnwould nnresult nnin
nninjury nnor
death nnto nnthe nnclient. nnThe nnsecond nnis nnwhen nnthe nnclient nnwaives nnthe nnright nnto
nngive nninformed
consent. nnOption nn1 nnwill nndelay nnemergency nntreatment, nnand nnoption nn2 nnis
nninappropriate.
Although nnoption nn4 nnmay nnbe nnpursued, nnit nnis nnnot nnthe nnbest nnaction nnbecause
nnit nndelays
necessary nnemergency nntreatment.
The nnnurse nnhas nnjust nnassisted nna nnclient nnback nnto nnbed nnafter nna nnfall. nnThe
nnnurse nnand nnprimary nnhealth nncare nnprovider nnhave nnassessed nnthe nnclient nnand
nnhave nndetermined nnthat nnthe nnclient nnis nnnot nninjured. nnAfter nncompleting nnthe
nnoccurrence nnreport, nnthe nnnurse nnshould nnimplement nnwhich nnaction nnnext?
1. nnReassess nnthe nnclient.
2. nnConduct nna nnstaff nnmeeting nnto nndescribe nnthe nnfall.
3. nnContact nnthe nnnursing nnsupervisor nnto nnupdate nninformation nnregarding
the nnfall.
4. nnDocument nnin nnthe nnnurse's nnnotes nnthat nnan nnoccurrence nnreport nnwas
completed. nn- nnAnswer nnAnswer: nn1
Rationale: nnAfter nna nnclient's nnfall, nnthe nnnurse nnmust nnfrequently nnreassess nnthe
nnclient,
because nnpotential nncomplications nndo nnnot nnalways nnappear nnimmediately nnafter
nnthe nnfall. nnThe
client's nnfall nnshould nnbe nntreated nnas nnprivate nninformation nnand nnshared nnon nna
nn"need nnto nnknow"
basis. nnCommunication nnregarding nnthe nnevent nnshould nninvolve nnonly nnthe
nnindividuals
participating nnin nnthe nnclient's nncare. nnAn nnoccurrence nnreport nnis nna nnproblem-
solving
document; nnhowever, nnits nncompletion nnis nnnot nndocumented nnin nnthe nnnurse's
nnnotes. nnIf nnthe
nursing nnsupervisor nnhas nnbeen nnmade nnaware nnof nnthe nnoccurrence, nnthe
nnsupervisor nnwill
contact nnthe nnnurse nnif nnstatus nnupdate nnis nnnecessary.
The nnnurse nnarrives nnat nnwork nnand nnis nntold nnto nnreport nn(float) nnto nnthe nnintensive
nncare nnunit nn(ICU) nnfor nnthe nnday nnbecause nnthe nnICU nnis nnunderstaffed nnand
,nnneeds nnadditional nnnurses nnto nncare nnfor nnthe nnclients. nnThe nnnurse nnhas nnnever
nnworked nnin nnthe nnICU. nnThe nnnurse nnshould nntake nnwhich nnbest nnaction?
1. nnRefuse nnto nnfloat nnto nnthe nnICU nnbased nnon nnlack nnof nnunit nnorientation.
2. nnClarify nnthe nnICU nnclient nnassignment nnwith nnthe nnteam nnleader nnto nnensure
that nnit nnis nna nnsafe nnassignment.
3. nnAsk nnthe nnnursing nnsupervisor nnto nnreview nnthe nnhospital nnpolicy nnon
floating.
4. nnSubmit nna nnwritten nnprotest nnto nnnursing nnadministration, nnand nnthen nncall
the nnhospital nnlawyer. nn- nnAnswer nnAnswer: nn2
Rationale: nnFloating nnis nnan nnacceptable nnpractice nnused nnby nnhospitals nnto nnsolve
understaffing nnproblems. nnLegally, nnthe nnnurse nncannot nnrefuse nnto nnfloat nnunless nna
nnunion
contract nnguarantees nnthat nnnurses nncan nnwork nnonly nnin nna nnspecified nnarea nnor
nnthe nnnurse nncan
prove nnthe nnlack nnof nnknowledge nnfor nnthe nnperformance nnof nnassigned nntasks.
nnWhen
encountering nnthis nnsituation, nnthe nnnurse nnshould nnset nnpriorities nnand nnidentify
nnpotential
areas nnof nnharm nnto nnthe nnclient. nnThat nnis nnwhy nnclarifying nnthe nnclient nnassignment
nnwith nnthe nnteam
leader nnto nnensure nnthat nnit nnis nna nnsafe nnone nnis nnthe nnbest nnoption. nnThe nnnursing
nnsupervisor nnis
called nnif nnthe nnnurse nnis nnexpected nnto nnperform nntasks nnthat nnhe nnor nnshe nncannot
nnsafely nnperform.
Submitting nna nnwritten nnprotest nnand nncalling nnthe nnhospital nnlawyer nnis nna
nnpremature nnaction.
The nnnurse nnwho nnworks nnon nnthe nnnight nnshift nnenters nnthe nnmedication nnroom
nnand nnfinds nna nncoworker nnwith nna nntourniquet nnwrapped nnaround nnthe nnupper
nnarm. nnThe nncoworker nnis nnabout nnto nninsert nna nnneedle, nnattached nnto nna nnsyringe
nncontaining nna nnclear nnliquid, nninto nnthe nnantecubital nnarea. nnWhich nnis nnthe nnmost
nnappropriate nnaction nnby nnthe nnnurse?
1. nnCall nnsecurity.
2. nnCall nnthe nnpolice.
3. nnCall nnthe nnnursing nnsupervisor.
4. nnLock nnthe nncoworker nnin nnthe nnmedication nnroom nnuntil nnhelp nnis nnobtained. nn-
nnAnswer nnAnswer: nn3
Rationale: nnNurse nnpractice nnacts nnrequire nnreporting nnimpaired nnnurses. nnThe
nnboard nnof
nursing nnhas nnjurisdiction nnover nnthe nnpractice nnof nnnursing nnand nnmay nndevelop
nnplans nnfor nn
treatment nnand nnsupervision nnof nnthe nnimpaired nnnurse. nnThis nnoccurrence nnneeds
nnto nnbe
, reported nnto nnthe nnnursing nnsupervisor, nnwho nnwill nnthen nnreport nnto nnthe nnboard nnof
nnnursing nnand
other nnauthorities, nnsuch nnas nnthe nnpolice, nnas nnrequired. nnThe nnnurse nnmay nncall
nnsecurity nnif nna
disturbance nnoccurs, nnbut nnno nninformation nnin nnthe nnquestion nnsupports nnthis nnneed,
nnand nnso
this nnis nnnot nnthe nnappropriate nnaction. nnOption nn4 nnis nnan nninappropriate nnand
nnunsafe nnaction.
A nnhospitalized nnclient nntells nnthe nnnurse nnthat nnan nninstructional nndirective nnis
nnbeing nnprepared nnand nnthat nnthe nnlawyer nnwill nnbe nnbringing nnthe nndocument nnto
nnthe nnhospital nntoday nnfor nnwitness nnsignatures. nnThe nnclient nnasks nnthe nnnurse nnfor
nnassistance nnin nnobtaining nna nnwitness nnto nnthe nnwill. nnWhich nnis nnthe nnmost
nnappropriate nnresponse nnto
the nnclient?
1. nn"I nnwill nnsign nnas nna nnwitness nnto nnyour nnsignature."
2. nn"You nnwill nnneed nnto nnfind nna nnwitness nnon nnyour nnown."
3. nn"Whoever nnis nnavailable nnat nnthe nntime nnwill nnsign nnas nna nnwitness nnfor nnyou."
4. nn"I nnwill nncall nnthe nnnursing nnsupervisor nnto nnseek nnassistance nnregarding
your nnrequest." nn- nnAnswer nnAnswer: nn4
Rationale: nnInstructional nndirectives nn(living nnwills) nnare nnrequired nnto nnbe nnin nnwriting
nnand
signed nnby nnthe nnclient. nnThe nnclient's nnsignature nnmust nnbe nnwitnessed nnby
nnspecified
individuals nnor nnnotarized. nnLaws nnand nnguidelines nnregarding nninstructional
nndirectives
vary nnfrom nnstate nnto nnstate, nnand nnit nnis nnthe nnresponsibility nnof nnthe nnnurse nnto
nnknow nnthe nnlaws.
Many nnstates nnprohibit nnany nnemployee, nnincluding nnthe nnnurse nnof nna nnfacility
nnwhere nnthe nnclient
is nnreceiving nncare, nnfrom nnbeing nna nnwitness. nnOption nn2 nnis nnnontherapeutic nnand
nnnot nna nnhelpful
response. nnThe nnnurse nnshould nnseek nnthe nnassistance nnof nnthe nnnursing
nnsupervisor.
The nnnurse nnhas nnmade nnan nnerror nnin nndocumentation nnof nnthe nndose
nnadministered nnof nnan nnopioid nnpain nnmedication nnin nnthe nnclient's nnrecord. nnThe
nnnurse nndraws nn1 nnmg nnfrom nnthe nnvial nnand nnanother nnregistered nnnurse nn(RN)
nnwitnesses nnwasting nnof nnthe
remaining nn1 nnmg. nnWhen nnscanning nnthe nnmedication, nnthe nnnurse nnentered nninto
nnthe nnmedication nnadministration nnrecord nn(MAR) nnthat nn2 nnmg nnof nnhydromorphone
nnwas nnadministered nninstead nnof nnthe nnactual nndose nnadministered, nnwhich nnwas nn1
nnmg. nnThe
nurse nnshould nntake nnwhich nnaction(s) nnto nncorrect nnthe nnerror nnin nnthe nnMAR?
nnSelect nnall nnthat nnapply.
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