HESI SAUNDERS ONLINE NCLEX (2E)
MODULE 5 Exam Questions And Answers
100% Pass
A licensed practical nurse arrives at work at the long-term care center and is immediately faced with
several activities that require attention. Which activity will the nurse attend to first?
a. Stocking the medicati...
A licensed practical nurse arrives at work at the long-term care center and is immediately faced with
several activities that require attention. Which activity will the nurse attend to first?
a. Stocking the medication closet
b. Task assignments for the day
c. A phone message from a client's wife
d. A phone message from employee health services - answer✔b. Task assignments for the day
Rationale:
The nurse must attend to task assignments first because client care is the priority. Also, the nursing staff
need their assignments so that they may begin client care. The nurse should next check the medication
supply to ensure that needed medications are available. The nurse would next return the phone calls.
TEST TAKING STRATEGIES:
Note the strategic word "first," and use the process of elimination and prioritization skills. Remember
that the client is the priority. Eliminate the options that are not directly related to immediate client
needs. This will direct you to the correct option. Review the principles of prioritization and time
management if you had difficulty with this question.
A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's
record indicate an unexpected outcome and the need for follow-up?
a. A client is performing his own colostomy irrigations.
b. A client with a central venous catheter has a temperature of 100.6°F.
c. A client with a new diagnosis of diabetes mellitus is self-administering insulin.
d. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
e. A client who has just undergone surgery is getting relief from the prescribed pain medication. -
answer✔b. A client with a central venous catheter has a temperature of 100.6°F.
Rationale:
A case manager is a nurse who assumes responsibility for coordinating a client's care from the point of
admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical
pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case
manager monitors the client for expected and unexpected outcomes and provides follow-up and revises
the plan of care if an unexpected outcome is noted. A temperature of 100.6°F in a client with a central
venous catheter is an unexpected and unwanted outcome, requiring the need for follow-up because it
may indicate the development of an infection. The other options all represent expected outcomes.
TEST TAKING STRATEGIES:
Think about the role of the case manager, and read each client description carefully. Next, focus on the
subject, an unexpected outcome and the need for follow-up. This will direct you to the outcome that is
unexpected or unwanted. An increased temperature is a concern because it is a sign of infection. Review
the role of the case manager and information on these expected and unexpected outcomes if you had
difficulty with this question.
A client with cancer is transported to the radiology department for a bone scan to determine whether
the cancer has metastasized to bone. While the client is in the radiology department, the client's wife
arrives for a visit and asks what test is being performed on the client. What should the nurse tell the
wife?
a. A bone scan is being performed.
b. She will have to discuss the prescribed test with the client.
c. The radiology department is not clear as to which test has been prescribed.
d. She can read the client's medical record to determine what the health care provider prescribed. -
answer✔b. She will have to discuss the prescribed test with the client.
Rationale:
Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the
appropriate response is to tell the client's wife that she will have to discuss the test with the client.
Likewise, a client's medical record is confidential and cannot be given to the wife for reading. Telling the
client's wife that the radiology department is unclear as to what test has been prescribed is
inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on
another department.
TEST TAKING STRATEGIES:
Use the process of elimination. Focusing on the subject, confidentiality, and recalling the issues
surrounding confidentiality will direct you to the correct option. Review the issues surrounding
confidentiality if you had difficulty with this question.
A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication.
On further assessment, the nurse notes that the client experiences increased pain during passive
motion, compared with active motion, of the left arm. On the basis of these assessment findings, which
action should the nurse take first?
a. Contacting the health care provider
b. Reassessing the client in 30 minutes
c. Checking to see whether it is time for more pain medication
d. Encouraging the client to continue active range of motion exercises of the left arm - answer✔a.
Contacting the health care provider
Rationale:
The client with early acute compartment syndrome typically complains of severe diffuse pain that is
unrelieved by pain medication. The affected client also complains that pain during passive motion is
greater than that during active motion. The nurse must notify the health care provider immediately. The
other options are incorrect because they delay necessary interventions.
TEST TAKING STRATEGIES:
Focus on the assessment data presented in the question. Recall that these signs indicate early acute
compartment syndrome. Remember, if this is suspected, the health care provider needs to be notified.
Also note that the incorrect options are comparable or alike options that delay necessary intervention.
Review the complications associated with a fracture of an extremity and the associated priority nursing
interventions if you had difficulty with this question.
A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has
contracted a sexually transmitted infection. In regard to informed consent, the nurse provides the client
with which information?
a. She will need to sign an informed consent form.
b. Her mother or father will need to be contacted for permission to treat her.
c. Anyone over the age of 18 years may sign a consent form for her treatment.
d. A consent form is not needed if the problem is a sexually transmitted infection. - answer✔a. She will
need to sign an informed consent form.
Rationale:
Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A
consent form is needed if the problem is a sexually transmitted infection. If the client is a minor, he or
she may sign the informed consent in the following situations: if the client is an emancipated minor; if
the client is seeking birth control services or is pregnant; if the client is seeking treatment for a sexually
transmitted infection, drug or substance abuse, or psychiatric services; or if a court order or other legal
authorization has been obtained.
TEST TAKING STRATEGIES:
Eliminate the comparable or alike options that indicate that the consent form must be signed by another
individual. To select from the remaining options, recall that a consent form is required for treatment.
Review the issues related to informed consent if you had difficulty with this question.
A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record
reflects the correct use of guidelines for documentation?
a. The client seems anxious.
b. The client's intake was 360 mL
c. The client's wound is healing well.
d. The client is voiding large amounts. - answer✔b. The client's intake was 360 mL
Rationale:
Quality documentation and reporting have five important characteristics: factual, accurate, complete,
current, and organized. Using an accurate measurement of intake is correct. The use of the word
"seems" indicates that the nurse did not know the facts. Using the word "well" is also incorrect, because
it does not provide an accurate observation. Likewise, using the word "large" does not provide an
accurate measurement.
TEST TAKING STRATEGIES:
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