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 HESI
Comprehensive Review for the

NCLEX- RN ®

Examination

EDITION

Student Resources on Evolve

Evolve * Access Code Inside
FI.SRY 1FR
HESI Comprehensive Review for the
NCLEX-RN® Examination

SIXTH EDITION

E. Tina Cuellar, PhD, WHNP, PMHCNS, BC

Director of Live Review, Elsevier/HESI, Houston, Texas

2
Table of Contents

Cover image

Title page

Copyright

Contributing Authors

Preface

1. Introduction to Test-Taking Strategies and the NCLEX-RN®

Test-Taking Strategies

The NCLEX-RN

Job Analysis Studies

The NCLEX-RN Computer Adaptive Testing

Gentle Reminders of General Principles

2. Leadership and Management: Legal Aspects of Nursing

Legal Aspects of Nursing

Prescriptions and Health Care Providers

Review of Legal Aspects of Nursing

Leadership and Management

Maintaining a Safe Work Environment

Communication Skills

3
 Review of Leadership and Management

Disaster Nursing

Ebola

Review of Disaster Nursing

3. Advanced Clinical Concepts

Respiratory Failure

Respiratory Failure in Children

Review of Respiratory Failure

Shock

Disseminated Intravascular Coagulation (DIC)

Review of Shock and DIC

Resuscitation

Management of Foreign Body Airway Obstruction (FBAO)

Review of Resuscitation

Fluid and Electrolyte Balance

Review of Fluid and Electrolyte Balance

Electrocardiogram (ECG)

Review of Electrocardiogram (ECG)

Perioperative Care

Review of Perioperative Care

HIV Infection

Pediatric HIV Infection

Review of HIV Infection

Pain: Fifth Vital Sign

Review of Pain

4
 Death and Grief

Review of Death and Grief

4. Medical-Surgical Nursing

Communication

Health Promotion and Disease Prevention

Teaching/Learning

Spiritual Assessment

Cultural Diversity

Complementary and Alternative Interventions

Respiratory System

Review of Respiratory System

Renal System

Review of Renal System

Cardiovascular System

Review of Cardiovascular System

Gastrointestinal (GI) System

Review of Gastrointestinal System

Endocrine System

Review of Endocrine System

Musculoskeletal System

Review of Musculoskeletal System

Neurologic System

Review of Neurologic System

Hematology and Oncology

Review of Hematology and Oncology

5
 Reproductive System

Review of Reproductive System

Burns

Review of Burns

5. Pediatric Nursing

Growth and Development

Pain Assessment and Management in the Pediatric Client

Review of Child Health Promotion

Respiratory Disorders

Review of Respiratory Disorders

Cardiovascular Disorders

Review of Cardiovascular Disorders

Neuromuscular Disorders

Review of Neuromuscular Disorders

Renal Disorders

Review of Renal Disorders

Gastrointestinal Disorders

Review of Gastrointestinal Disorders

Hematologic Disorders

Review of Hematologic Disorders

Metabolic and Endocrine Disorders

Review of Metabolic and Endocrine Disorders

Skeletal Disorders

Review of Skeletal Disorders

6. Maternity Nursing

6
 Anatomy and Physiology of Reproduction

Antepartum Nursing Care

Review of Anatomy and Physiology of Reproduction and Antepartum Nursing Care

Fetal and Maternal Assessment Techniques

Review of Fetal and Maternal Assessment Techniques

Intrapartum Nursing Care

Review of Intrapartum Nursing Care

Normal Puerperium (Postpartum)

Review of Normal Puerperium (Postpartum)

The Normal Newborn

Review of the Normal Newborn

High-Risk Disorders

Review of High-Risk Disorders

Postpartum High-Risk Disorders

Review of Postpartum High-Risk Disorders

Newborn High-Risk Disorders

Effects on the Neonate of Substance Abuse

7. Psychiatric Nursing

Therapeutic Communication

Coping Styles (Defense Mechanisms)

Treatment Modalities

Review of Therapeutic Communication and Treatment Modalities

Anxiety and Related Disorders

Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Traumatic and

Stressor Related Disorders

Review of Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and

7
 Traumatic and Stressor Related Disorders

Somatic Symptom Disorder and Related Disorders

Review of Somatic Symptom Disorder and Related Disorders

Dissociative Disorders

Review of Dissociative Disorders

Personality Disorders (DSM-5 Criteria)

Review of Personality Disorders

Eating Disorders

Review of Eating Disorders

Mood Disorders

Review of Mood Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Review of Thought Disorders

Substance Abuse Disorder

Substance Use Disorder

Review of Substance Abuse Disorder

Abuse

Review of Abuse

Neurocognitive Disorder (DSM-5)

Review of Neurocognitive Disorders

Childhood and Adolescent Disorders

Review of Childhood and Adolescent Disorders

8. Gerontologic Nursing

Theories of Aging

Neurocognitive Disorder (NCD): Dementia

8
 Psychosocial Changes

Health Maintenance and Preventive Care

Review of Gerontologic Nursing

Answer Key to Review Questions

APPENDIX. Common Laboratory Tests

Index

9
Contributing Authors

Safa’a Al-Arabi, PhD, RN, MSN, MPH , Associate Professor and Master’s Track
Administrator, University of Texas Medical Branch, Galveston, Texas

Karen Alexander, PhD, RN , Program Director at University of Houston Clear Lake,

Pearland, Texas

Joanna Cain, BSN, BA, RN , President and Founder, Auctorial Pursuits, Inc., Austin,
Texas

Lucindra Campbell-Law, PhD, ANP, PMHNP, BC , Professor, Carol and Odis Peavy
School of Nursing, University of St. Thomas, Houston, Texas

E. Tina Cuellar, PhD, WHNP, PMHCNS, BC , Director of Live Review,

Elsevier/Education/HESI, Houston, Texas

Claudine Dufrene, PhD, RN-BC, GNP-BC, CNE , Assistant Professor, Carol and Odis
Peavy School of Nursing, University of St. Thomas, Houston, Texas

Sandra Jenkins, PhD, RN , Visiting Professor, University of Houston Clear Lake,

Pearland, Texas

Shatoi King, MSN, RN , Instructor, University of Houston Clear Lake, Pearland, Texas

Necole Leland, MSN, RN, PNP, CPN , Instructor, School of Nursing, University of
Nevada, Las Vegas, Las Vegas, Nevada

Katherine Ralph, EdD, RN , Nurse Manager Curriculum, Review and Testing,

Elsevier/Education/HESI, Houston, Texas

12
Preface

Welcome to HESI Comprehensive Review for the NCLEX-RN ® Examination with online study
exams by HESI.
Congratulations! This outstanding review manual with online study exams is designed to
prepare nursing students for what is very likely the most important examination they will
ever take—the NCLEX-RN Licensing Examination. HESI Comprehensive Review for the
NCLEX-RN ® Examination allows the nursing student to prepare for the NCLEX-RN
licensure examination in a structured way.

• Organize previously learned basic nursing knowledge.

• Review content learned during basic nursing curriculum.
• Identify deficits in content knowledge so that study effort can be focused
appropriately.
• Develop test-taking skills to demonstrate application of safe nursing practice.
• Reduce anxiety level by increasing predictability of ability to correctly answer
NCLEX-type questions.
• Boost test-taking confidence by being well prepared and knowing what to expect.

13
Organization AND PREPARING TO TAKE TESTS
Chapter 1 , Introduction to Test-Taking Strategies and the NCLEX-RN ® , gives an
overview of the NCLEX-RN Licensing Examination history and test plan for the
examination. Reviews of the nursing process, client needs, and strategies for employing
clinical judgement to prioritize nursing care are also presented.
Chapter 2 , Leadership and Management, reviews the legal aspects of nursing,
leadership and management, and disaster nursing.
Chapter 3 , Advanced Clinical Concepts, presents nursing assessment, analysis, and
planning and intervention, using clinical judgment at the highest level of practice. Topics
reviewed include respiratory failure, shock, disseminated intravascular coagulation,
resuscitation, fluid and electrolyte balance, intravenous therapy, acid–base balance,
electrocardiogram, perioperative care, HIV, pain, and death and grief.
Chapters 4 through 8 , Medical-Surgical Nursing, Pediatric Nursing, Maternity
Nursing, Psychiatric Nursing, and Gerontologic Nursing, are presented in traditional
clinical areas. Each clinical area is divided into physiologic components, with essential
knowledge about basic anatomy, growth and development, pharmacology and medication
calculation, nutrition, communication, client and family education, acute and chronic care,
leadership and management, complementary and alternative interventions, cultural and
spiritual diversity, and clinical decision making threaded throughout the different
components.
Open-ended questions with the answers appear at the end of each chapter, which
encourage the student to think in depth about the content that is presented throughout the
particular chapter. When a variety of learning mechanisms are used, students have the
opportunity to comprehensively prepare for the NCLEX exam; these strategies include:

• Reading the manual

• Discussing content with others
• Answering open-ended questions
• Practicing with study exams that simulate the licensure examination

These learning experiences are all different ways that students should use to prepare for
the NCLEX-RN exam. The purpose of the open-ended questions appearing at the end of the
chapter is not a focused practice session on managing NCLEX-style questions, but rather a
learning approach that allows for more in-depth thinking about specific topics in the
chapter. Practice with multiple-choice questions alone cannot provide the depth of critical
thinking and analysis that is made possible by the short-answer questions at the end of the
chapter. In addition, the open-ended questions presented at the end of the chapter provide
a summary experience that helps students focus on the main topics that were covered in the
chapter. Teachers use open-ended questions to stimulate the critical-thinking process, and
HESI Comprehensive Review for the NCLEX-RN ® Examination facilitates the critical-thinking
process by posing the same type of questions the teacher might ask.
When students need to practice multiple-choice questions, the online study exams on

14
Evolve offer extensive opportunities for practice and skill building to improve their test-
taking abilities. The online study exams include six content-specific exams (Medical-
Surgical Nursing, Pharmacology, Pediatrics, Fundamentals, Maternity, and Psychiatric-
Mental Health Nursing) and two comprehensive exams patterned after categories on the
NCLEX-RN exam. The online study exams on Evolve can be accessed as many times as
necessary, and the questions from one study exam are not contained on another study
exam. For instance, the Medical-Surgical study exam does not contain questions that are on
the Pediatrics study exam. The purpose of the study exams is to provide practice and
exposure to the critical thinking–style questions that students will encounter on the
NCLEX-RN exam. However, the study exams should not be used to predict performance
on the actual NCLEX-RN exam. Only the HESI Exit Exam, a secure, computerized exam
that simulates the NCLEX-RN test plan and has evidence-based results from numerous
research studies indicating a high level of accuracy in predicting NCLEX success, is offered
as a true predictor exam. Students are allowed unlimited practice on each online study
exam so that they can be sure to have the opportunity to review all of the rationales for the
questions.
Here is a plan for a student to use with the online study exams:

• Step 1: Take the RN study exam without studying for it to see where your
strengths and weaknesses are.
• Step 2: After going over the content that relates to the study questions in a
particular clinical area (e.g., Pediatrics, Medical-Surgical, or Maternity), review
that section of the manual and take the test again to determine whether you have
been able to improve your scores.
• Step 3: Purposely miss every question on the exam so that you can view the
rationales for every question.
• Step 4: Take the exam again under timed conditions at the pace that you would
have to progress in order to complete the NCLEX-RN exam in the time allowed
(approximately 1 minute per question). See if being placed under time constraints
affects your performance.
• Step 5: Put the exam away for a while and continue review and remediation with
other textbooks, resources, and results of any HESI secure exams that you have
taken at your school. Then, take the study exams again to see if your performance
improves after in-depth study and following a few weeks’ break from these
questions.

Step 5 represents a good activity in preparation for the HESI Exit Exam presented in your
final semester of the nursing program, especially if you have not used the online study
exams for several weeks. Repeated exposure to the questions, however, will make them less
useful over time because students tend to memorize the answers. For this reason, these tests
are useful only for practice and not for prediction of NCLEX-RN success. The tendency to
memorize the questions after viewing them multiple times falsely elevates a student’s score
on the study exams.
Additional assistance for students studying for the NCLEX-RN Licensing Examination
can be obtained from a variety of online products in the Elsevier family. Many nursing
schools have also adopted the following:

15
• HESI Examinations—A comprehensive set of examinations designed to prepare
nursing students for the NCLEX exam. They include customized electronic
remediation from current Elsevier textbooks and multimedia, as well as additional
practice questions. Each student is given an individualized report detailing exam
results and is allowed to view questions and rationales for items that were
answered incorrectly. The electronic remediation, a complementary feature of the
specialty and exit exams, can be filed by the student for later study.
• HESI Practice Test—This is the ideal way to practice for the NCLEX exam. With
more than 1200 practice questions included in this online test bank, nursing
students can access practice exams 24 hours a day, 7 days a week. HESI Practice
Test questions are written at the critical-thinking level so that students are tested
not for memorization but for their skills in clinical application. Students select a
test option (either a clinical specialty or a comprehensive exam), and HESI Practice
Test automatically supplies a series of critical-thinking practice questions. NCLEX
exam–style questions include multiple-choice and alternate-item formats and are
accompanied by correct answers and rationales.
• HESI RN Case Studies—These prepare students to manage complex patient
conditions and make sound clinical judgments. These online case studies cover a
broad range of physiologic and psychosocial alterations, plus related
management, pharmacology, and therapeutic concepts.
• HESI Patient Reviews—These are designed to teach and assess students’ retention
of core nursing content. These online interactive reviews provide a firsthand look
at safe and effective nursing care.
• HESI Live Review—A live review course is presented by an expert faculty member
who has additional instruction in working with students who are preparing to
take the NCLEX exam. Students are presented with a workbook and practice
NCLEX-style questions that are used during the course.
• Evolve eBooks—Online versions of all of the Mosby, Saunders, and Elsevier
textbooks used in the student’s nursing curriculum are presented. Search across
titles, highlight, make notes, and more—all on your computer.
• Elsevier Simulations—Virtual versions simulate the clinical environment. These
multilayered, complex, supplemental simulations enable students to experience
clinical assignments without the need for actual clinical space.
• Elsevier Courses—These are created by experts using instructional design
principles. This interactive content engages students with reading, animation,
video, audio, interactive exercises, and assessments.

16
Next Generation NCLEX and Clinical Judgment
Starting in July of 2017, the National Council of State Boards of Nursing (NCSBN) began
including a special research section to select candidates after they complete the exam.
The data collected from this section is used to help determine new item types that may
be included in a future version of the NCLEX, known as Next Generation NCLEX
(NGN). (More information can be found at ( http://www.ncsbn.org/next-generation-
nclex.htm. ) An important piece of the NGN is the clinical judgment model. Clinical
judgment is important for all nurses, and this book helps nursing students by reviewing
information and skills that nurses must master to practice clinical judgment.
Additionally, NCLEX practice questions on the Evolve website written at higher levels of
Bloom’s taxonomy help students practice applying their clinical judgment knowledge.
Finally, a Clinical Judgment Scenario with practice NGN questions is included in
Chapter 4 to familiarize students with these types of questions .

17
Introduction to Test-Taking Strategies and
the NCLEX-RN®
Congratulations! You have made the wise decision to prepare, in a structured way, for the
NCLEX-RN®.

A. Since you have successfully completed a basic nursing program and are well
acquainted with your test-taking skills and ability to apply your clinical
knowledge, you already have the basic knowledge required to pass the licensing
examination.
B. However, following these general guidelines will help ensure your success.
1. Organize your knowledge.
2. Identify weaknesses in content knowledge to help focus your study
time appropriately.
3. Review the need-to-know content learned in nursing school.
4. Develop strong test-taking skills to demonstrate your knowledge.
5. Reduce your level of anxiety by dissecting test questions and using
your foundational knowledge to arrive at the correct answer.
6. Know what to expect. Remember that knowledge is power. You are
powerful when you are well prepared and know what to expect.

18
Test-Taking Strategies
These test-taking strategies help you focus your study so that you can concentrate on what
the exam questions are asking instead of being distracted by extraneous information that is
not needed to answer the questions.

A. The NCLEX-RN tests your knowledge about several core concepts and the ability
to synthesize information to effectively apply, analyze, or evaluate a client’s needs
to provide safe and effective care. For example, a question may appear to be a
medical-surgical or pediatric question, but the question can also cover such topics
as communication, nutrition, growth and development, medication, client and
family education, and safety.

HESI Hint
The most essential element of nursing care is client safety.

B. Understand the question.

1. Determine whether the question is written in a positive or negative
style.
a. A positive style question may ask what the nurse should
do or ask for the best or first nursing intervention to
implement.

HESI Hint
Most questions are written in a positive style.

b. A negative style question may ask what the nurse should

avoid, which prescription the nurse should question, or
which behavior indicates the need for reteaching the
client.

HESI Hint
Negative style questions contain key words that denote the negative style.
Examples

1. “Which response indicates to the nurse a need to reteach the client about heart
disease?” (Which information or understanding by the client is incorrect?)
2. “Which medication order should the nurse question?” (Which prescription is unsafe,
not beneficial, inappropriate to this client situation?)

C. Identify key words.

19
 1. Ask yourself which words or phrases provide the critical information.
2. This information may include the age of the client, the setting, the
timing, a set of symptoms or behaviors, or any number of other factors.
a. For example, the nursing actions for a 10-year-old postop
client are different from those for a 70-year-old postop
client.
D. Rephrase the question.
1. Rephrasing the question helps eliminate nonessential information in
the question to help you determine the correct answer.
a. Ask yourself, “What is this question really asking?”
b. While keeping the options covered, rephrase the question
in your own words.
2. Rule out options.
a. Based on your knowledge, you can most likely identify
one or two options that are clearly incorrect.
b. Physically mark through those options on the test booklet
if allowed. Mentally mark through those options in your
head if using a computer.
c. Differentiate between the remaining options, considering
your knowledge of the subject and related nursing
principles, such as roles of the nurse, nursing process,
ABCs (airway, breathing, circulation), CAB (circulation,
airway, breathing for cardiopulmonary resuscitation
[CPR]), and Maslow’s hierarchy of needs.
E. Implement these guidelines.
1. Consider the content of the question and what specifically the question
is asking.
2. Generally, an assessment of the client occurs before an action is taken,
except in the case of an emergency, for example, if a client is bleeding
profusely, stop the bleeding. Or, if a client is having difficulty
breathing, open the airway then assess the client.
3. Identify the least invasive intervention before taking action.
4. Gather all of the necessary information and complete the necessary
assessments before calling the healthcare provider.
5. Determine which client to assess first (e.g., most at risk, most
physiologically unstable).
6. Identify opposites in the answers.
a. Example: prone versus supine; elevated versus decreased.
b. Read VERY carefully; one opposite is likely to be the
answer, but not always.
c. If you do not know the answer, choose the most likely of
the “opposites” and move on.
7. Take into account a client’s lifestyle, culture, and spiritual beliefs when
answering a question.
F. Use your critical thinking skills.
1. Respond to questions based on
a. Client safety

20
 b. ABCs
c. CAB for CPR
d. Caring
e. Incorporation of culture and spiritual practices
f. Scientific, behavioral, and sociologic principles
g. Communication (spoken and written [documentation])
with client, family, colleagues, and other members of the
healthcare team
h. Principles of teaching and learning
i. Maslow’s hierarchy of needs
j. Nursing process
k. Focus on what information is in the stem. Do not focus on
information not included in the question. Do not read
more into the question than is already there.
1. NCLEX-RN ideal hospital
2. Basic anatomy and physiology
2. Do not respond to questions based on
a. YOUR past client care experiences or your employer’s
policies
b. A familiar phrase or term
c. “Of course, I would have already”
d. What you think is realistic; perceptions of realism are
subjective
e. Your children, pregnancies, parents, personal response to
a drug, etc.
f. The “what-ifs”

HESI Hint
As soon as you are seated in the testing area, use the erasable noteboard to write
down information you’ve memorized (a brain dump). That’s a resource you
may use while testing if you become too stressed to recall information you
memorized.

G. Keep memorization to a minimum.

1. Don’t try to memorize all of the material found in your textbooks
because it isn’t possible. Only memorize core concepts.
a. Growth and developmental milestones
b. Death and dying stages
c. Crisis intervention
d. Immunization schedules
e. Principles of teaching and learning
f. Stages of pregnancy and fetal growth
g. Nurse Practice Act: Standards of Practice and Delegation
h. Ethical practices and standards
i. Commonly used laboratory test values:
1. Review Appendix A.
2. Hemoglobin and hematocrit (H&H)

21
 3. White blood cells (WBCs), red blood cells
(RBCs), platelets
4. Electrolytes: K+, Na+, Ca++, Mg++, Cl − ,

5. Blood urea nitrogen (BUN) and creatinine

6. Relationship of Ca++ and
7. Arterial blood gases (ABGs)
8. SED rate, erythrocyte sedimentation rate
(ESR), prothrombin time (PT),
international normalized ratio (INR),
partial thromboplastin time (PTT),
activated partial thromboplastin time
(aPTT)

HESI Hint
Remember not to confuse PT, PTT, and aPTT.

j. Nutrition
1. High or low Na+
2. High or low K+
3. High
4. Iron
5. Vitamin K
6. Proteins
7. Carbohydrates
8. Fats
k. Foods and diets related to
1. Body system disturbances (cardiac,
endocrine, gastrointestinal)
2. Chemotherapy, radiation, surgery
3. Pregnancy and fetal growth needs
4. Dialysis
5. Burns
l. Nutrition concepts
1. Introduce one food at a time for infants
and clients with allergies.
2. Progression to “as tolerated” foods and
diets
H. Understand medication administration.
1. Safe medication administration requires more than knowing the name,
classification, and action of the medication.
a. The Six Rights, including techniques of skill execution
b. Drug interactions
c. Vulnerable organs to medication effects
1. Know what to assess (kidney function,
vital signs).

22
 2. Know which laboratory values relate to
specific organs and their functions.
d. Client allergies
e. Presence of infections and superinfections
f. Concepts of peak and trough levels
g. How you would know if
1. The drug is working.
2. There is a problem.
h. Nursing actions
i. Client education
1. Safety
2. Empowerment
3. Compliance

23
The NCLEX-RN
A. The main purpose of the NCLEX-RN is to protect the public.
B. The NCLEX-RN
1. Was developed by the National Council of State Boards of Nursing
(referred to as “the Council” throughout this book)
2. Is administered by the State Board of Nurse Examiners
3. Is designed to test candidates’
a. Capabilities for safe and effective nursing practice
b. Essential entry-level nursing knowledge
c. Ability to problem solve by applying critical thinking
skills

24
Job Analysis Studies
A. Essential knowledge that new nurses should know is determined by job analysis
studies.
B. Job analysis studies indicate that newly licensed registered nurses are using all five
categories of the nursing process and that such use is evenly distributed
throughout the nursing process areas. Therefore, equal attention is given to each
part of the nursing process in selecting NCLEX-RN items (Table 1.1).

TABLE 1.1

The Nursing Process

HESI Hint
The Council wants to ensure that the licensing examination measures current entry-level
nursing behaviors. For this reason, job analysis studies are conducted every 3 years. These
studies determine how frequently various types of nursing activities are performed, how
often they are delegated, and how critical they are to client safety, with criticality given
more value than frequency.

Nursing Diagnoses
A. Nursing diagnoses are formulated during the analysis portion of the nursing
process. They give form and direction to the nursing process, promote priority
setting, and guide nursing actions (Table 1.2).
B. To qualify as a nursing diagnosis, the primary responsibility and accountability for
recognition and treatment rest with the nurse.

25
 C. NCLEX-RN questions regarding nursing diagnosis can take several forms.
1. You may be given the nursing diagnosis in the stem and asked to select
an appropriate nursing intervention based on the stated nursing
diagnosis.
2. You may be asked to select, from among the choices provided, the
most appropriate nursing diagnosis(es) for the described case.
3. You may be asked to choose, from four nursing diagnoses, the one that
should have priority based on the data in the stem.
D. For further information about nursing diagnoses, review a fundamentals text, a
medical-surgical nursing text, or a nursing diagnosis handbook.

HESI Hint
A nursing diagnosis must be subject to oversight by nursing management. It is not a
medical diagnosis. The cause may or may not arise from a medical diagnosis.

Client Needs
A. Job analysis studies have identified categories of care provided by nurses called
client needs. The test plan is structured according to these categories (Table 1.3).

Prioritizing Nursing Care

A. Many NCLEX-RN items are designed to test your ability to set priorities.
1. Identify the most important client needs.
2. Which nursing intervention is most important?

TABLE 1.2

Components of a Nursing Diagnosis

TABLE 1.3

Components of the NCLEX-RN Test Plan

26
27
28
 3. Which nursing action should be performed first?
4. Which response is best?
B. Setting priorities
1. Which action should be performed first or next? Remember, client
safety is paramount.
2. Remember Maslow (Table 1.4).
3. The Five Rights of Delegation (see Chapter 2, p. 16)

HESI Hint
Answering NCLEX-RN questions often depends on setting priorities, making judgments
about priorities, and analyzing the data and formulating a decision about care based on

29
priorities. Using Maslow’s hierarchy of needs can help you set nursing priorities.

30
The NCLEX-RN Computer Adaptive Testing
A. Computer adaptive testing (CAT) is used for implementation of the NCLEX-RN.
B. The CAT is administered at a testing center selected by the Council.
C. Pearson VUE is responsible for adapting the NCLEX-RN to the CAT format,
processing candidate applications, and transmitting test results to its data center
for scoring.
D. The testing centers are located throughout the United States.
E. The Council generates the NCLEX-RN questions.

TABLE 1.4

Maslow’s Hierarchy of Needs

Need Definition Nursing Implications

Physiologic Biologic needs for The priority biologic need is breathing (i.e., an open airway). Review Table
food, shelter, water,1.3, which lists activities associated with physiologic integrity. If asked to
sleep, oxygen, identify the most important action, identify needs associated with
sexual expression physiologic integrity (e.g., providing an open airway) as the most
important nursing action.
Safety Avoiding harm; Review Table 1.3, which lists the activities associated with a safe and
attaining security, effective care environment. Ensuring that the client’s environment is safe is
order, and physical a priority (e.g., teaching an older client to remove throw rugs that pose a
safety safety hazard when ambulating has a greater priority than teaching the
client how to use a walker). The first priority is safety, followed by coping
skills.
Love and Giving and Although these needs are important (described in Table 1.3), they are less
Belonging receiving important than physiologic or safety needs. For example, it is more
Esteem and affection; important for a client to have an open airway and a safe environment for
Recognition companionship; ambulating than it is to assist him or her to become part of a support
identification group. However, assisting the client in becoming a part of a support group
with a group has higher priority than assisting in the development of self-esteem. The
Self-esteem and sense of belonging comes first, and such a sense may help in developing
respect of self-esteem.
others; success
in work;
prestige
Self- Fulfillment of It is important to understand the last two needs in Maslow’s hierarchy.
Actualization unique They could deal with client needs associated with health promotion and
Aesthetic potentialSearch for maintenance, such as continued growth and development and self-care, as
beauty and spiritual well as those associated with psychosocial integrity. However, you will
goals probably not be asked to prioritize needs at this level. Remember, it is the
goal of the Council to ensure safe nursing practice, and such practice does
not usually deal with the client’s self-actualization or aesthetic needs.

How CAT Works

A. The NCLEX-RN consists of 75 to 265 multiple-choice or alternative-format
questions (15 of which are pilot items) presented on a computer screen.
B. The candidate is presented with a test item and possible answers.
C. If the candidate answers the question correctly, a slightly more difficult item will

31
 follow, and the level of difficulty will increase with each item until the candidate
misses an item.
D. If the candidate misses an item, a slightly less difficult item will follow, and the
level of difficulty will decrease with each item until the candidate has answered an
item correctly.
E. This process will continue until the candidate has achieved a definite pass or a
definite fail score. There will be no borderline pass or fail scores because the
adaptive testing method determines the candidate’s level of performance before
she or he has finished the examination.
F. The lowest number of items a candidate can answer to complete the examination is
75; 15 of them will be pilot items and will not count toward the pass or fail score;
60 of them will determine the candidate’s score.
G. The number of the item the candidate is currently answering will appear on the
upper-right area of the screen.
H. When the candidate has answered enough items to determine a definite pass or
fail score, a message will appear on the screen notifying the candidate that he or
she has completed the examination.
I. The greatest number of items a candidate can answer is 265, and the longest
amount of time the candidate can take to complete the examination is 6 hours.
J. Candidates will have up to 6 hours to complete the NCLEX-RN; total examination
time includes a short tutorial, two preprogrammed optional breaks, and any
unscheduled breaks the candidate may take. The first optional break is offered
after 2 hours of testing. The second optional break is offered after 3.5 hours of
testing. The computer will automatically tell candidates when these scheduled
breaks begin.
1. All breaks count against testing time.
2. When candidates take breaks, they must leave the testing room, and
they will be required to provide a palm vein scan before and after the
breaks.
K. If a candidate has not obtained a pass or fail score at the end of the 6 hours and has
not completed all 265 items in the 6-hour limit, but has answered all of the last 60
questions presented correctly, he or she will pass the examination.
L. If a candidate has not obtained a pass or fail score at the end of the 6 hours, has not
completed all 265 items in the 6-hour limit, and has not answered correctly all of
the last 60 questions presented, he or she will fail the examination.
M. A specific passing score is recommended by the Council. All states require the
same score to pass, so that if you pass in one state, you are eligible to practice
nursing in any other state. However, states do differ in their requirements
regarding the number of times a candidate can take the NCLEX-RN.
N. Although the Council has the ability to determine a candidate’s score at the time of
completion of the examination, it has been decided that it would be best for
candidates to receive their scores from their individual Board of Nurse Examiners.
The Council does not want the testing center to be in a position of having to deal
with candidates’ reactions to scores, nor does the Council want those waiting to
take their examinations to be influenced by such reactions.
O. The candidate must answer each question in order to proceed. You cannot omit a
question or return to an item presented earlier. There is no going back; this works

32
 in your favor!
P. The examination is written at a tenth-grade reading level.
Q. There is no penalty for guessing.
R. The NCSBN Candidate Bulletin is available at https://www.ncsbn.org/1213.htm.
Then select: Examinations/Candidates/Basic Information/Bulletin.

HESI Hint
For multiple choice questions, one or more of the answer choices is likely to be very wrong.
You usually will be able to rule out two of the four choices rather quickly. Reread the
question and choices again if necessary. Ask yourself which choice answers the question
being asked. Even if you have absolutely no idea what the correct answer is, you will have
a 50/50 chance of guessing the right answer if you follow this process. Your first response
will provide an educated guess and will usually be the correct answer. Go with your gut
response!

Examination Item Formats

A. A number of different types of examination items are presented on the NCLEX-
RN. Many of the questions are multiple-choice items with four answer choices
from which the candidate is asked to choose one correct answer. There are seven
alternate format item types of questions.
1. Multiple-response items require the candidate to select one or more
responses. The item will instruct the candidate to select all that apply.
2. Fill-in-the-blank questions require the candidate to calculate the
answer and type in numbers. A drop-down calculator is provided.
3. Hot-spot items require the candidate to identify an area on a picture or
graph and click on the area.
4. Chart or exhibit formats present a chart or exhibit that the candidate
must read to be able to solve the problem.
5. Drag-and-drop items require a candidate to rank order or move
options to provide the correct order of actions or events.
6. Audio format items require the candidate to listen to an audio clip
using headphones and then select the correct option that applies to the
audio clip.
7. Graphic format items require the candidate to choose the correct
graphic option in response to the question.
B. There is no set percentage of alternative items on the NCLEX-RN. All examination
items are scored either right or wrong. There is no partial credit in scoring any
examination questions.

33
Gentle Reminders of General Principles
A. Be sure to take care of yourself. If you don’t, you may be susceptible to illness that
can cause you to miss the exam.
B. Eat well. Consume lots of fresh fruits, vegetables, and lean protein, and avoid high-
fat foods and sugars. Processed sugar can cause blood sugar levels to spike and
then plummet, which can cause brain fogginess.
C. Get enough sleep. This includes getting enough sleep the week of, not just the
night before, the exam. The week of the exam is not the time to cram or to party.
D. Eliminate alcohol and other mind-altering drugs. These substances can inhibit
your performance on the examination.
E. Schedule study times. During the weeks leading up to the examination, review
nursing content, focusing on areas that you have identified as your weakest areas.
Use a study schedule to block out the time needed for study.
F. Be prepared. Assemble all necessary materials the night before the examination
(admission ticket, directions to the testing center, identification, money for lunch,
glasses or contacts).
G. Bring the necessary items to the exam. Candidates are only allowed to bring a form
of identification into the testing room. Watches, candy, chewing gum, food, drinks,
purses, wallets, pens, pencils, beepers, cellular phones, Post-It notes, study
materials or aids, and calculators are not permitted. A test administrator will
provide each candidate with an erasable noteboard that may be replaced as needed
while testing. Candidates may not take their own noteboards, scratch paper, or
writing instruments into the examination. A calculator on the computer screen will
be available for use.
H. Arrive early. Allow plenty of time to eat breakfast and travel to the testing center.
It is better to be early than late. Allow for traffic jams and so forth. The candidate
may consider spending the night in a hotel or motel near the testing center the
night before the examination.
I. Dress comfortably. Dress in layers so that you can put on or take off a sweater or
jacket as needed.
J. Avoid negative people. During the weeks leading up to the examination, stay away
from those who share their anxieties with you or project their insecurities onto you.
Sometimes this is a fellow classmate or even your best friend. The person will still
be there when the examination is over. Stay focused and positive.
K. Do not discuss the exam. Avoid talking about the examination during breaks and
while waiting to take the test.
L. Avoid distractions. Take earplugs with you and use them if you find that those
around you are distracting you. The rattling of paper or a candidate getting up to
leave the exam room can be distracting.
M. Think positively. Use the affirmation, “I am successful.” Obtain a relaxation and
affirmation recording, and use it during rest periods or any time you feel the need
to boost your confidence. Think, “I have the knowledge to successfully complete
the NCLEX-RN.”

34
HESI Hint
The night before the NCLEX-RN, allow only 30 minutes of study time. This 30-minute
period should be designated for review of test-taking strategies only. Practice these
strategies with various practice test items if you wish (for 30 minutes only; do not take an
entire test). Spend the night before the examination doing something that you enjoy.
Engage in stress reduction and do not use alcohol or other mind-altering drugs. Only you
can identify the special something that will work for you. Remember, you can be
successful!

For more review, go to http://evolve.elsevier.com/HESI/RN for HESI’s online study

examinations.

35
Leadership and Management

Legal Aspects of Nursing

36
Legal Aspects of Nursing
Laws Governing Nursing
A. Nurse Practice Acts provide the laws that control and regulate nursing practice in
each state to protect the public from harm. Mandatory Nurse Practice Acts
authorize that, under the law, only licensed professionals can practice nursing. All
states now have mandatory Nurse Practice Acts. Laws affecting nursing practice
vary from state to state.
B. Nurse Practice Acts govern the nurse’s responsibility in making assignments. Each
state sets its own educational and examination requirements.
1. Client assignments should be commensurate with the nursing
personnel’s educational preparation, skills, experience, and knowledge.

HESI Hint
Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state
govern policies related to making assignments. Usually, when determining who should be
assigned to do a sterile dressing change, for example, a licensed nurse should be chosen—
that is, a registered nurse (RN) or licensed practical nurse (LPN) who has been checked off
on this procedure.

2. The nurse should supervise the care provided by unlicensed assistive

personnel (UAP) or any individual for which the nurse is
administratively responsible.
3. Sterile or invasive procedures should be assigned to or supervised by
an RN.
4. Documenting client care is a legal task.

Torts (Violation of Client’s Private Right)

Unintentional Torts
A. Definition: An act involving injury or damage to another (except breach of
contract) resulting in civil liability (i.e., the victim can sue) instead of criminal
liability (see Crime).
B. Negligence and malpractice.
1. Negligence: Performing an act that a reasonable and prudent person
would not perform. The measure of negligence is “reasonableness”
(i.e., would a reasonable and prudent nurse act in the same manner
under the same circumstances?). That is, did the nurse provide care
that did not meet the standard?
2. Malpractice: Negligence by professional personnel (e.g., professional
misconduct or unreasonable lack of skill in carrying out professional

37
 duties). Malpractice is a negligent act performed by an individual in a
professional role that results in an injury.
C. Four elements are necessary to prove malpractice; if any one element is missing,
malpractice cannot be proved.
1. Duty: Obligation to use due care (what a reasonable, prudent nurse
would do); failure to care for and/or to protect others against
unreasonable risk. The nurse must anticipate foreseeable risks. Example:
If a floor has water on it, the nurse is responsible for anticipating the
risk of a client fall.
2. Breach of duty: Failure to perform according to the established
standard of conduct in providing nursing care.
3. Injury/damages: Failure to meet the standard of care, which causes
actual injury or damage to the client (physical injury). Neither
emotional nor mental injury is enough to prove malpractice, either
physical or mental.
4. Causation: A connection exists between conduct and the resulting
injury, referred to as proximate cause or remoteness of damage.
D. Hospital policies provide a guide for nursing actions. They are not laws, but courts
generally rule against nurses who have violated the employer’s policies. Hospitals
can be liable for poorly formulated or poorly implemented policies.

HESI Hint
Nurses can avoid negligence and malpractice by following their organization’s policies
and procedures.

E. Incident reports alert the administration to possible liability claims and the need
for investigation; they do not protect against legal action being taken for
negligence or malpractice.
F. Examples of negligence or malpractice:
1. Burning a client with a heating pad
2. Leaving sponges or instruments in a client’s body after surgery
3. Performing incompetent assessments
4. Failing to heed warning signs of shock or impending myocardial
infarction
5. Ignoring signs and symptoms of bleeding
6. Forgetting to give a medication or giving the wrong medication

Intentional Torts
A. Assault and battery
1. Assault: Mental or physical threat (e.g., forcing [without touching] a
client to take a medication or treatment)
2. Battery: Actual and intentional touching of one another, with or
without the intent to do harm (e.g., hitting or striking a client). If a

38
 mentally competent adult is forced to have a treatment he or she has
refused, battery occurs.
B. Invasion of privacy: Encroachment or trespassing on another’s body or personality
1. False imprisonment: Confinement without authorization
2. Exposure of a person:
a. Body: After death, a client has the right to be unobserved,
excluded from unwarranted operations, and protected
from unauthorized touching of the body.
b. Personality: Exposure or discussion of a client’s case or
revealing personal information or identity.
3. Defamation: Divulgence of privileged information or communication
(e.g., through charts, conversations, or observations)
C. Fraud: Illegal activity and willful and purposeful misrepresentation that could
cause, or has caused, loss or harm to a person or property. Examples of fraud
include
1. Presenting false credentials for the purpose of entering nursing school,
obtaining a license, or obtaining employment (e.g., falsification of
records).
2. Describing a myth regarding a treatment (e.g., telling a client that a
placebo has no side effects and will cure the disease, or telling a client
that a treatment or diagnostic test will not hurt, when indeed pain is
involved in the procedure).

Crime
A. An act contrary to a criminal statute. Crimes are wrongs punishable by the state
and committed against the state, with intent usually present. The nurse remains
bound by all criminal laws.
B. Commission of a crime involves the following behaviors:
1. A person commits a deed contrary to criminal law.
2. A person omits an act when there is a legal obligation to perform such
an act (e.g., refusing to assist with the birth of a child if such a refusal
results in injury to the child).
3. Criminal conspiracy occurs when two or more persons agree to
commit a crime.
4. Assisting or giving aid to a person in the commission of a crime makes
that person equally guilty of the offense (awareness must be present
that the crime is being committed).
5. Ignoring a law is not usually an adequate defense against the
commission of a crime (e.g., a nurse who sees another nurse taking
narcotics from the unit supply and ignores this observation is not
adequately defended against committing a crime).
6. Assault is justified for self-defense. However, to be justified, only
enough force can be used to maintain self-protection.
7. Search warrants are required before searching a person’s property.
8. It is a crime not to report suspected child abuse.

39
HESI Hint
The nurse has a legal responsibility to report suspected child abuse.

Nursing Practice and the Law

Psychiatric Nursing
A. Civil procedures: Methods used to protect the rights of psychiatric clients
B. Voluntary admission: The client admits himself or herself to an institution for
treatment and retains civil rights.
C. Involuntary admission: Someone other than the client applies for the client’s
admission to an institution.
1. This requires certification by a health care provider that the person is a
danger to self or others. (Depending on the state, one or two health
care provider certifications are required.)
2. Individuals have the right to a legal hearing within a certain number of
hours or days.
3. Most states limit commitment to 90 days.
4. Extended commitment is usually no longer than 1 year.
D. Emergency admission: Any adult may apply for emergency detention of another.
However, medical or judicial approval is required to detain anyone beyond 24
hours.
1. A person held against his or her will can file a writ of habeas corpus to
try to get the court to hear the case and release the person.
2. The court determines the sanity and alleged unlawful restraint of a
person.
E. Legal and civil rights of hospitalized clients
1. The right to wear their own clothes and to keep personal items and a
reasonable amount of cash for small purchases
2. The right to have individual storage space for one’s own use
3. The right to see visitors daily
4. The right to have reasonable access to a telephone and the opportunity
to have private conversations by telephone
5. The right to receive and send mail (unopened)
6. The right to refuse shock treatments and lobotomy
F. Competency hearing: Legal hearing that is held to determine a person’s ability to
make responsible decisions about self, dependents, or property
1. Persons declared incompetent have the legal status of a minor—they
cannot
a. Vote
b. Make contracts or wills
c. Drive a car
d. Sue or be sued
e. Hold a professional license
2. A guardian is appointed by the court for an incompetent person.

40
 Declaring a person incompetent can be initiated by the state or the
family.
G. Insanity: Legal term meaning the accused is not criminally responsible for the
unlawful act committed because he or she is mentally ill
H. Inability to stand trial: Person accused of committing a crime is not mentally
capable of standing trial. He or she
1. Cannot understand the charge against himself or herself
2. Must be sent to the psychiatric unit until legally determined to be
competent for trial
3. Once mentally fit, must stand trial and serve any sentence, if convicted

Patient Identification
A. The Joint Commission has implemented new patient identification requirements to
meet safety goals
(http://www.jointcommission.org/standards_information/npsgs.aspx).
B. Use at least two patient identifiers. Ask the client to tell you his or her name and
date of birth (DOB) whenever taking blood samples, administering medications, or
administering blood products.
C. The patient room number may not be used as a form of identification.

Surgical Permit
A. Consent to operate (surgical permit) must be obtained before any surgical
procedure, however minor it might be.
B. Legally, the surgical permit must be
1. Written
2. Obtained voluntarily
3. Explained to the client (i.e., informed consent must be obtained)
C. Informed consent means the procedure and treatment or operation has been fully
explained to the client, including
1. Possible complications, risks, and disfigurements
2. Removal of any organs or parts of the body
3. Benefits and expected results
D. Surgery permits must be obtained as follows:
1. They must be witnessed by an authorized person, such as the health
care provider or a nurse.
2. They protect the client against unsanctioned surgery, and they protect
the health care provider and surgeon, hospital, and hospital staff
against possible claims of unauthorized operations.
3. Adults and emancipated minors may sign their own operative permits
if they are mentally competent.
4. Permission to operate on a minor child or an incompetent or
unconscious adult must be obtained from a legally responsible parent
or guardian. The person granting permission to operate on an adult
who lacks capacity to understand information about the proposed

41
 treatment (e.g., because of advanced Alzheimer disease or unconscious
adult) must be identified in a Durable Power of Attorney or an
Advance Health Directive.

HESI Hint
Often an NCLEX-RN question asks who should explain and describe a surgical procedure
to the client, including both complications and the expected results of the procedure. The
answer is the health care provider. Remember that it is the nurse’s responsibility to be sure
that the operative permit is signed and is in the client’s medical record. It is not the nurse’s
responsibility to explain the procedure to the client. The nurse must document that the
client was given the information and agreed to it.

Consent
A. The law does not require written consent to perform medical treatment.
1. Treatment can be performed if the client has been fully informed about
the procedure.
2. Treatment can be performed if the client voluntarily consents to the
procedure.
3. If informed consent cannot be obtained (e.g., client is unconscious) and
immediate treatment is required to save life or limb, the emergency
laws can be applied. (See the subsequent section, Emergency Care.)
B. Verbal or written consent
1. When verbal consent is obtained, a notation should be made.
a. It describes in detail how and why verbal consent was
obtained.
b. It is placed in the client’s record or chart.
c. It is witnessed and signed by two persons.
2. Verbal or written consent can be given by
a. Alert, coherent, or otherwise competent adults
b. A parent or legal guardian
c. A person in loco parentis (a person standing in for a
parent with a parent’s rights, duties, and responsibilities)
in cases of minors or incompetent adults
C. Consent of minors
1. Minors 14 years of age and older must agree to treatment along with
their parents or guardians.
2. Emancipated minors can consent to treatment themselves. Be aware
that the definition of an emancipated minor may change from state to
state.

Emergency Care
A. Good Samaritan Act: Protects health care providers against malpractice claims for

42
 care provided in emergency situations (e.g., the nurse gives aid at the scene to an
automobile accident victim).
B. A nurse is required to perform in a “reasonable and prudent manner.”

HESI Hint
Often NCLEX-RN questions address the Good Samaritan Act, which is the means of
protecting a nurse when she or he is performing emergency care.

43
Prescriptions and Health Care Providers
A. A nurse is required to obtain a prescription (order) to carry out medical
procedures from a health care provider.
B. Although verbal telephone prescriptions should be avoided, the nurse should
follow the agency’s policy and procedures. Failure to follow such rules could be
considered negligence. The Joint Commission requires that organizations
implement a process for taking verbal or telephone orders that includes a read-
back of critical values. The employee receiving the prescription should write the
verbal order or critical value on the chart or record it in the computer and then
read back the order or value to the health care provider.
C. If a nurse questions a health care provider’s (e.g., physician, advanced practice RN,
physician’s assistant, dentist) prescription because he or she believes that it is
wrong (e.g., the wrong dosage was prescribed for a medication), the nurse should
do the following:
1. Inform the health care provider.
2. Record that the health care provider was informed and record the
health care provider’s response to such information.
3. Inform the nursing supervisor.
4. Refuse to carry out the prescription.
D. If the nurse believes that a health care provider’s prescription was made with poor
judgment (e.g., the nurse believes the client does not need as many tranquilizers as
the health care provider prescribed), the nurse should
1. Record that the health care provider was notified and that the
prescription was questioned
2. Carry out the prescription because nursing judgment cannot be
substituted for a health care provider’s judgment
E. If a nurse is asked to perform a task for which he or she has not been prepared
educationally (e.g., obtain a urine specimen from a premature infant by needle
aspiration of the bladder) or does not have the necessary experience (e.g., a nurse
who has never worked in labor and delivery is asked to perform a vaginal
examination and determine cervical dilation), the nurse should do the following:
1. Inform the health care provider that he or she does not have the
education or experience necessary to carry out the prescription.
2. Refuse to carry out the prescription.

HESI Hint
If the nurse carries out a health care provider’s prescription for which he or she is not
prepared and does not inform the health care provider of his or her lack of preparation, the
nurse is solely liable for any damages.
If the nurse informs the health care provider of his or her lack of preparation in carrying
out a prescription and carries out the prescription anyway, the nurse and the health care
provider are liable for any damages.

44
 F. The nurse cannot, without a health care provider’s prescription, alter the amount of
drug given to a client. For example, if a health care provider has prescribed pain
medication in a certain amount and the client’s pain is not, in the nurse’s
judgment, severe enough to warrant the dosage prescribed, the nurse cannot
reduce the amount without first checking with the health care provider.
Remember, nursing judgment cannot be substituted for medical judgment.

Restraints
A. Clients may be restrained only under the following circumstances:
1. In an emergency
2. For a limited time
3. For the purpose of protecting the client from injury or from harm
B. Nursing responsibilities with regard to restraints
1. The nurse must notify the health care provider immediately that the
client has been restrained.
2. It is required and imperative that the nurse accurately document the
facts and the client’s behavior leading to restraint.
C. When restraining a client, the nurse should do the following:
1. Use restraints (physical or chemical) after exhausting all reasonable
alternatives.
2. Apply the restraints correctly and in accordance with facility policies
and procedures.
3. Check frequently to see that the restraints do not impair circulation or
cause pressure sores or other injuries.
4. Allow for nutrition, hydration, and stimulation at frequent intervals.
5. Remove restraints as soon as possible.
6. Document the need for and application, monitoring, and removal of
restraints.
7. Never leave a restrained person alone.

HESI Hint
Restraints of any kind may constitute false imprisonment. Freedom from unlawful
restraint is a basic human right and is protected by law. Use of restraints must fall within
guidelines specified by state law and hospital policy.

Health Insurance Portability and Accountability Act of 1996

A. Congress passed the Health Insurance Portability and Accountability Act of 1996
(HIPAA) to create a national patient-record privacy standard.
B. HIPAA privacy rules pertain to health care providers, health plans, and health
clearinghouses and their business partners who engage in computer-to-computer
transmission of health care claims, payment and remittance, benefit information,
and health plan eligibility information, and who disclose personal health

45
 information that specifically identifies an individual and is transmitted
electronically, in writing, or verbally.
C. Patient privacy rights are of key importance. Patients must provide written
approval of the disclosure of any of their health information for almost any
purpose. Health care providers must offer specific information to patients that
explains how their personal health information will be used. Patients must have
access to their medical records, and they can receive copies of them and request
that changes be made if they identify inaccuracies.
D. Health care providers who do not comply with HIPAA regulations or make
unauthorized disclosures risk civil and criminal liability.
E. For further information, use this link to the Department of Health and Human
Services (DHHS) website, Office of Civil Rights, which contains frequently asked
questions about HIPAA standards for privacy of individually identifiable health
information: http://aspe.hhs.gov/admnsimp/final/pvcguide1.htm.

46
Review of Legal Aspects of Nursing
1. What types of procedures should be assigned to professional nurses?
2. Negligence is measured by reasonableness. What question might the nurse ask
when determining such reasonableness?
3. List the four elements that are necessary to prove malpractice (professional
negligence).
4. Define an intentional tort and give one example.
5. Differentiate between voluntary and involuntary admission.
6. List five activities a person who is declared incompetent cannot perform.
7. Name three legal requirements of a surgical permit.
8. Who may give consent for medical treatment?
9. What law protects the nurse who provides care or gives aid in an emergency
situation?
10. What actions should the nurse take if the nurse questions a health care provider’s
prescription—that is, believes the prescription is wrong?
11. Describe the nurse’s legal responsibility when asked to perform a task for which he
or she is unprepared.
12. Describe nursing care of the restrained client.
13. Describe six patient rights guaranteed under HIPAA regulations that nurses must
be aware of in practice.
See Answer Key at the end of this text for suggested responses.

47
Another random document with
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stages between San Antonio, Texas, and San Diego, California.
Finally, in 1858, the Government established the “Butterfield
Overland Mail,” which ran a semi-weekly line of coaches from St.
Louis to San Francisco, by way of El Paso, Yuma and the Colorado
Desert, on a time schedule of twenty five days. This line was well
equipped with more than a hundred specially constructed Concord
coaches, a thousand horses, seven hundred mules, and about one
hundred and fifty drivers. It received from the Government a subsidy
of $600,000 a year, and was the longest continuous horse-express
line then in existence on the North American continent. Until the
outbreak of the Civil War, this southern route was the main artery of
travel from the eastern States to the Pacific Coast; and it is
estimated that, between 1849 and 1860, eight thousand emigrants
crossed the Colorado Desert on their way to California.
Of all these eight thousand gold-seekers or pioneers, only one
seems to have been impressed by the agricultural possibilities of the
Salton Sink. Dr. O. M. Wozencraft, who has been described as “a
man of marked personality and far-reaching vision who lived a
generation before his time,” crossed the Sink on his way to San
Bernardino sometime in the early fifties; noticed the deposit of silt in
the bed of the ancient lake; observed that the shallow basin lay so
far below the level of the Colorado River that it might easily be
irrigated therefrom; and reached the conclusion, previously stated by
Professor Blake, that the arid waste of the Sink, if adequately
supplied with water, could be made to “yield crops of almost any
kind.” This idea so took possession of his mind that, during the next
five or six years, he spent much of his time and a large part of his
private means in promoting schemes for the irrigation of this desert
area. His engineer, Ebenezer Hadley of San Diego, made a
preliminary survey of the Sink, and recommended a canal location
practically identical with that which forty years later was adopted. In
1859, upon the initiative of Dr. Wozencraft, the California legislature
asked Congress to cede to the State 3,000,000 acres of arid land,
including the Salton Sink, for irrigation purposes. The bill was
favorably reported by a House committee, but failed to pass. The
Congressmen of that time regarded the reclamation of the Colorado
Desert as a subject for jocular rather than serious treatment, and
most of them were in sympathy with the California humorist, J. Ross
Browne, who said: “I can see no great obstacle to success except
the porous nature of the sand. By removing the sand from the
desert, success would be insured at once.”
With the failure of Dr. Wozencraft’s attempt to bring about the
reclamation of the Colorado Desert, interest in that region gradually
waned. The Butterfield Overland Mail service to the Pacific Coast
was discontinued; a new “Pony Express” line to San Francisco, by
way of Salt Lake City, was established; and before 1865, the
southern route, via Yuma and the Colorado Desert, had been
practically abandoned. Dr. Wozencraft continued talking, to all who
would listen, about his scheme for the irrigation of the Salton Sink;
but most people regarded it as visionary, and nobody seemed
inclined to take it up. Only in 1891, thirty eight years after Professor
Blake first suggested irrigation, and twenty nine years after Dr.
Wozencraft’s bill failed in Congress, was a serious attempt made to
realize the “dream” of turning water into the Salton Sink and creating
a fertile oasis in the heart of the Colorado Desert.

FOOTNOTES:
[1] Rep. of U. S. Geolog. Survey for 1916.
[2] “The Imperial Valley and Salton Sink,” by H. T. Cory,
formerly Chief Engineer of the California Development Co., p. 49;
San Francisco 1915 (embodying paper read Jan. 8, 1913, before
the Amer. Soc. of Civil Engineers and published in its
Transactions as “Paper 1270”).
 THE CREATION OF THE OASIS
In 1891, John C. Beatty, of California, another man who had
imagination and foresight, became interested in the agricultural
possibilities of the Colorado Desert, and formed a corporation under
the name of “The California Irrigation Company” for the purpose of
carrying water into the Salton Sink from the Colorado River. He
engaged as his technical adviser Mr. C. R. Rockwood, who had been
in the employ of the U. S. Reclamation Service, and who was
regarded as “a shrewd and clever man and engineer.”[3] Mr.
Rockwood made a careful survey of the Colorado delta, and found,
as Lieutenant Bergland had found in an earlier survey, that between
the river and the Sink there was a natural obstacle in the shape of a
range of sand hills, which extended southward to the border line of
Mexico. All natural overflows of the river, in prehistoric times, had
been south of this barrier, and Mr. Rockwood thought that it would be
easier and more economical to follow the river’s ancient track than to
put a conduit through these hills on the American side of the
boundary. He proposed, therefore, to take water from the Colorado
at Potholes, twelve miles above Yuma, carry it southward into
Mexico, thence westward around the promontory of sand hills, and
finally northward, across the line again, into southern California. This
plan would involve the digging of a curving canal, forty or fifty miles
in length, through Mexican territory; but it would obviate the
necessity of cutting through the sand hills, and would perhaps
enable the diggers to utilize, on the Mexican side, one of the dry
barrancas, or ancient overflow channels, through which the Colorado
discharged into the Sink in ages past.
 Relief Map of Imperial Valley and Its Environment
Owing to the lack of public confidence in reclamation experiments,
Mr. Beatty and his associates were not able to secure as much
capital as they needed for their enterprise, and when the monetary
panic of 1893 came, they found themselves involved in financial
difficulties from which they could not extricate themselves. In the
latter part of 1893 the California Irrigation Co. went into bankruptcy,
and its maps, records, and engineering data were turned over to Mr.
Rockwood, in satisfaction of a judgment that he obtained in a suit for
his unpaid salary.[4]
 This seemed likely to put an end to the Salton Sink project; but Mr.
Rockwood, whose observations and work in the Colorado delta had
given him unbounded faith in the ultimate success of the scheme,
determined to undertake the promotion of it himself. After several
years of endeavor, he succeeded in forming another organization
which was incorporated in New Jersey, on the 21st of April 1896,
under the title of “The California Development Company.” For two
years or more, this corporation tried to get permission from the
Mexican Government to hold land, acquire rights, and dig an
irrigating canal south of the boundary line; but the Mexican
authorities refused to make any concessions, and it was finally found
necessary to organize a subsidiary Mexican company. This
corporation, which had a nominal capital of $62,000, was wholly
owned and controlled by the California Development Co., but it
operated under a Mexican charter.
As the financial resources of both companies were largely on
paper, it then became necessary to secure real capital for the
prosecution of the work, and this task Mr. Rockwood found extremely
difficult. The proposed reclamation of an arid desert, where the
thermometer went in summer to 120 in the shade, and where only
two or three inches of rain fell in the course of the whole year, did not
strike Eastern capitalists as a very promising venture, and most of
them were disinclined to go into it. At last, however, in 1898, Mr.
Rockwood secured a promise from certain capitalists in New York
that they would advance the necessary funds; but two days before
the papers were to be signed, the American battleship “Maine” was
blown up in the harbor of Havana, and this catastrophe, together
with the war that followed it, put an end to the negotiations.
But the plan for the irrigation of the Salton Sink was not destined
to fail. Among the men with whom Dr. Wozencraft discussed it, in the
early eighties, was George Chaffey, a civil engineer and irrigation
expert of Los Angeles, who had had a good deal of experience in
dealing with water problems, and who had already established
successful irrigation systems in other parts of California.[5] Mr.
Chaffey declined to go into it at Dr. Wozencraft’s solicitation, not
because he was afraid of the engineering difficulties involved, but
because he thought that the torrid climate of the Sink would prevent
colonization of it, even if the colonists were promised plenty of water.
Most men, he reasoned, would be frightened by the prospect of
having to do hard agricultural labor in shade temperatures of 110 to
120, and sun temperatures of perhaps 140 to 150. They simply
would not go to a place where they would be subjected to such heat.
Some years later, however, Mr. Chaffey carried through successfully
an irrigation enterprise in the interior of Australia, where the
temperature in the shade often reached a maximum of 125, but
where, nevertheless, men were able to work without danger or
serious inconvenience. This changed his view of irrigation in the
Colorado Desert; and in 1900, when the California Development Co.
seemed unable to get money enough for its project elsewhere, Mr.
Chaffey offered to finance the undertaking and superintend the work.
His proposals were accepted, and on the 3rd of April 1900, he
became president of the company, and signed a contract by which
he bound himself to construct canals, at a cost of not more than
$150,000, which would carry to the Imperial Valley 400,000 acre-feet
of water per annum.[6]
Mr. Chaffey and his associates modified the plan of Mr. Rockwood
by taking water from the Colorado at Pilot Knob, nearly opposite
Yuma, instead of at Potholes, twelve miles above. Putting in a head-
gate there, they carried their main canal southward across the
Mexican boundary, in a course nearly parallel with the river, until they
reached the barranca, or dry overflow channel, known as the Alamo.
As this ancient watercourse meandered westward in the direction of
the Salton Sink, they were able to clear it out, enlarge it, and utilize
most of it as a part of their irrigation system. Then, at a point about
forty miles west of the Colorado, they carried their canal northward,
across the boundary line again, into southern California. The work
throughout was pushed with great energy, and on the 14th of May,
1901, a little more than a year after Mr. Chaffey assumed direction of
affairs, water was turned in at the Pilot Knob head-gate, and the
irrigation of the Salton Sink became a certainty, if not a fully
accomplished fact.
 As the California Development Co. was a water-selling company
only, and had no proprietary interest in the lands to be irrigated, it
was thought best to form another organization for the promotion of
settlement; and in March 1901 the Imperial Land Company was
incorporated for the purpose of attracting colonists, laying out town
sites, and developing the Sink by bringing its lands into cultivation.
Then Mr. Chaffey and the Land Company began an advertising
campaign for the purpose of interesting the general public in the
scheme; and in order not to frighten settlers and small investors by
using in their advertisements and circulars the ominous words
“desert” and “Sink,” they changed the name of the basin that they
proposed to irrigate and called it “The Imperial Valley.” This title was
evidently alluring, because it attracted small investors in all parts of
the East, and particularly in New England. The Development
Company’s stock was bought, for example, in places as far away
from the Salton Sink as Boston, Concord, Hopedale and Waverley,
Mass.; Barre and Montpelier, Vt.; Portsmouth, N. H.; Elgin, Ill.;
Portland, Oregon; and Toronto, Canada.[7] Settlers soon began to
come in; mutual water companies were organized; and before the
3rd of April 1902, when Mr. Chaffey severed his connection with the
company, four hundred miles of irrigating ditches had been dug, and
water was available for 100,000 acres or more of irrigable land.[8]
About this time, however, the future of the Valley was seriously
imperilled by unfavorable reports concerning its soil. In the early part
of 1902, the Bureau of Soils of the U. S. Agricultural Department
published the results of a survey of the irrigable lands in the
Colorado Desert, and reported that they were so impregnated with
alkali that very few things could be successfully grown on them.
“One hundred and twenty five thousand acres of land” (the
report said) “have already been taken up by prospective
settlers, many of whom talk of planting crops which it will be
absolutely impossible to grow. They must early find that it will
be useless to attempt their growth.... No doubt the best thing
to do is to raise such crops as sugar beet, sorghum, and date
palm (if the climate will permit), that are suited to such alkali
conditions, and abandon as worthless the lands which contain
 too much alkali to grow those crops.” (“Field Operations of the
Bureau of Soils, U. S. Department of Agriculture,” 1901, p.
587.)
This report, which was widely quoted and commented upon, acted
as a serious check to the colonization of the Valley; and if it had
been made two or three years earlier, it might have been fatal to the
whole irrigation project. Fortunately, however, the crops raised by a
few farmers who had already been cultivating this “alkali
impregnated” land proved conclusively that the report of the analysis
of the soil made by the Government experts was unduly pessimistic,
if not wholly erroneous. Almost everything that was tried did grow, in
spite of expert predictions, and the practical experience of men on
the ground gradually revived public confidence in the productiveness
of the irrigated lands. The colonization and development of the
Valley then proceeded with great rapidity. The two thousand settlers
on the ground at the end of 1902 increased to seven thousand in
1903 and to more than ten thousand in 1904. A branch of the
Southern Pacific railroad was built through the Valley from Imperial
Junction to Calexico and Mexicali; town sites were laid out in six or
seven different places; the water system was extended by the
digging of nearly four hundred additional miles of irrigating ditches
and canals; and before the 1st of January 1905, one hundred and
twenty thousand acres of reclaimed land were actually under
cultivation, while two hundred thousand acres more had been
covered by water stock.
 Colorado Delta and Imperial Valley
The observed fertility of the soil completely discredited the reports
of the Government experts, and more than justified the prediction
made by Professor Blake half a century before that when the Sink
should be supplied with water, it would produce “crops of almost any
kind.” Grapes, melons and garden vegetables matured in the Valley
earlier than in any other part of California; barley was a profitable
crop; alfalfa could be cut five or six times a year; and the finest
quality of long-staple Egyptian cotton yielded more than a bale (500
pounds) to the acre. Experiments proved also that the climate and
soil were well adapted to the culture of grapes, grapefruit, oranges,
lemons, olives, figs, dates, pomegranates, apricots, peaches and
pears.
The fear that men would not be willing or able to do hard work in
the hot climate of the valley proved to be wholly groundless. Great
heat is not necessarily weakening or prostrating unless it is
accompanied with great humidity, and the air of the Valley is at all
seasons extremely dry. In a discussion of this subject, Mr. H. T. Cory,
formerly chief engineer of the California Development Co., says:
“The climate of the region, with its long, hot, dry summers,
is peculiarly favorable to agricultural luxuriance. Thus it is that
here the very earliest grapes, fruits and vegetables are
produced for the United States market, with the consequent
advantage of commanding the highest prices. This is notably
true of the Imperial Valley cantaloupe, now famous all over
this country, and of the early grapes, asparagus etc. On
account of the very low humidity and gentle winds which blow
most of the time in hot weather, the sensible temperature—
which is indicated by the wet-bulb thermometer readings and
gives the measure of heat felt by the human body—is much
less than the actual temperature as measured by the dry bulb.
It is conservative to say that a temperature of 110 in Imperial
Valley is not more uncomfortable than 95 in Los Angeles, or
85 in the more humid sections of the Eastern States.
Furthermore the nights are always cool, the low humidity
resulting in rapid and large daily temperature variations.”
Under these favoring conditions of soil and climate, it seemed
almost certain, in 1904, that the Imperial Valley would have a great
and prosperous future; but no forecast in that region is trustworthy
unless it takes into account the irrigating agency, as well as the
climate and the soil. The Colorado River created the Salton Sink,
and made fertile the Imperial Valley; but it could destroy, as well as
create; and in 1904 it showed itself in a new aspect and threatened
the Valley with a terrible calamity.
A Part of the Colorado River Watershed. The Grand Cañon

FOOTNOTES:
[3] Mr. H. T. Cory.
[4] Mr. Cory.
[5] In his “Imperial Valley and Salton Sink,” Mr. H. T. Cory,
formerly chief engineer of the California Development Co., refers
to Mr. Chaffey in the following words:
“The writer takes pleasure in expressing appreciation of the
standing of Mr. George M. Chaffey in irrigation work in the West.
The Ontario Colony he founded in 1883 was selected ten years
later as a model for the irrigation exhibit at the World’s Exposition,
and in his work at Mildura, Australia, he designed, had built in
England, and installed, the first centrifugal pumps on the same
shaft with a total capacity of 320 cubic feet per second lifted 20
feet. He is at present, among other things, head of the
magnificent water system irrigating 10,000 acres of citrus lands
near Whittier, California, including the highest priced agricultural
lands in California ($5,000 per acre). Furthermore he is a man of
affairs, and of large means which he acquired principally in
irrigation enterprises and banking.”
[6] Andrew M. Chaffey.
[7] List of stockholders in Sou. Pac. office, N. Y.
[8] Andrew M. Chaffey.
 THE RUNAWAY RIVER
The most serious problem with which engineers have to deal in
the irrigation of arid land from a turbid river is the getting rid of silt,
and this problem is a particularly difficult one in the Imperial Valley,
owing to the immense amount of sediment that the irrigating water
contains. The Colorado River, until after it passes the Grand Cañon,
is almost everywhere a swift, turbulent stream, with great eroding
capacity. As Mr. E. C. LaRue has said, in a brief but graphic
description of it,
“When the snows melt in the Rocky and Wind River
Mountains, a million cascade brooks unite to form a thousand
torrent creeks; a thousand torrent creeks unite to form half a
hundred rivers beset with cataracts; half a hundred roaring
rivers unite to form the Colorado, which flows, a mad, turbid
stream, into the Gulf of California.” (“Colorado River and Its
Utilization,” a Geological Survey report, Government Printing
Office, Washington 1916.)
Such a river, naturally, dissolves the earth and gnaws the rocks
over which it tears its way, and takes up millions of tons of solid
matter, in the shape of gravel, sand and finely pulverized soil. This
great volume of sediment, when finally dropped, not only tends to
change the river’s course by creating bars at or near its mouth, but
gradually fills up the irrigating ditches and canals and thus lessens
their carrying capacity. A single day’s supply of water for the Imperial
Valley contains silt enough to make a levee twenty feet high, twenty
feet wide, and one mile long. (Imperial Valley Press, July 25 1916). If
this silt is not dredged out, sluiced out, or collected in a settling
basin, it eventually raises the beds of the canals, fills the ditches,
and chokes up the whole irrigation system.
The managers of the California Development Co. had difficulty,
almost from the first, in keeping their waterways open. As more and
more land was brought into cultivation, more and more water was
required, while the silting up of the canals lessened the ability of the
company to meet the constantly increasing demand. There was a
shortage as early as the winter of 1902-3; but the situation did not
become serious until the following year, when the main canal, for a
distance of four miles below the intake, became so silted up that it
could not possibly carry the volume of water that was imperatively
needed. An attempt was made to remedy this state of affairs by
putting in a waste-gate, eight miles below the intake, for the purpose
of sluicing out the channel in time of high water.
“The idea” (as stated by Mr. Cory) “was to divert a large
quantity of water during the flood season, waste it through the
Best waste-gate, and in this way scour out the upper portion
of the canal. At first, the action was as expected, and some
two feet in the bottom were carried away. When, however, the
river reached its maximum height, ... and carried an excessive
silt content, especially of the heavier and sandy type, this
scouring action was entirely overcome, and the bottom of this
stretch was raised approximately one foot higher than during
the previous year.”
This silting up of the main canal, and the consequent reduction of
its carrying capacity, caused great injury to the agricultural interests
of the Valley. Crops in many places perished for lack of water, and
hundreds of farmers put in damage claims, which amounted in the
aggregate to half a million dollars. In the late summer of 1904, it
became evident that radical measures would have to be taken at
once to increase the water supply. As the managers of the company
had neither the financial means nor the requisite machinery for
quickly dredging out the silted part of the canal, they decided, in
September of that year, to cut a new intake from the river at a point
about four miles south of the international boundary. This would
eliminate the choked-up part of the canal, and let water directly into
the part that was unobstructed.
 The Three Headings (or Intakes), in Spring of 1905
If President Heber and Chief Engineer Rockwood had been aware
of the fact that the Colorado was even then preparing to pour its
waters into the Salton Sink, by making one of its semi-millennial
changes of course, they might perhaps have fortified the western
bank instead of cutting through it; but there was little or nothing to
show the extreme instability of the conditions that were then
determining the trend of the river across its delta, and the idea that it
might burst through this intake and again turn the Valley into a fresh-
water lake does not seem to have occurred to anyone. The cutting
was therefore made and the water shortage relieved; but at the cost
of imminent peril to the whole Valley and its twelve thousand
inhabitants.
In view of the tremendous and disastrous consequences of this
measure, it is only fair that Chief Engineer Rockwood should be
allowed to state, with some fullness, his reasons for adopting it, and
for failing to put in a head-gate to control the flow of water through
the channel and thus prevent its enlargement. In an article entitled
“Born of the Desert,” published in the second annual magazine
number of the Calexico Chronicle, in May 1909, he sets forth his
reasons in the following words:
“As soon as the summer flood (1904) dropped, I discovered
that instead of the bottom” (of the canal) “being lower, it was
approximately one foot above that of the year previous.... We
knew that with the dredging tools which we had it would be
impossible to dredge out this four miles of canal in sufficient
time for the uses of the Valley, providing the water in the river
should drop as low as it had the previous year.... We were
then confronted with the proposition of doing one of two
things, either cutting a new heading from the canal to the river
below the silted four-mile section of the canal, or else allowing
the Valley to pass through another winter with an insufficient
water supply. The latter proposition we could not face, for the
reason that the people of the Valley had an absolute right to
demand that water should be furnished them, and it was
questionable in our minds as to whether we would be able to
keep out of bankruptcy if we were to be confronted by another
period of shortage in the coming season of 1904-1905.
“The cutting of the lower intake, after mature deliberation,
and upon the insistence of several of the leading men of the
Valley, was decided upon. We hesitated about making this
cut, not so much because we believed we were incurring
danger of the river’s breaking through, as from the fact that
we had been unable to obtain the consent of the Government
of Mexico to make it, and we believed that we were
jeopardizing our Mexican rights should the cut be made
without the consent of the Government. On a telegraphic
communication, however, from our attorney in the City of
Mexico, to go ahead and make the cut, we did so, under the
presumption that he had obtained the necessary permit from
the Mexican authorities. It was some time after this, in fact
after the cut was made in the river, before we discovered that
he had been unable to obtain the formal permit, but had
simply obtained the promise of certain officials that we would
not be interfered with, providing that plans were at once
submitted for the necessary controlling structures to be
placed in this heading.
“... In cutting from the main canal to the river at this point,
we had to dredge a distance of 3300 feet only, through easy
material to remove, while an attempt to dredge out the main
canal above would have meant the dredging of four miles of
very difficult material. We began the cut the latter end of
September and completed it in about three weeks. As soon
as the cut was decided upon, elaborate plans for a controlling
gate were immediately started, and when completed, early in
November, were immediately forwarded to the City of Mexico
for the approval of the engineers of the Mexican Government,
without whose approval we had no authority or right to
construct the gate. Notwithstanding the insistence of our
attorney in the City of Mexico, and various telegraphic
communications insisting upon this approval being hurried,
we were unable to obtain it until twelve months afterward,
namely, the month of December 1905.
“In the meantime, serious trouble had begun. We have
since been accused of gross negligence and criminal
carelessness in making this cut; but I doubt as to whether
anyone should be accused of negligence, or carelessness, in
failing to foresee what had never happened before. We had
before us at the time the history of the river as shown by the
rod-readings kept at Yuma for a period of twenty seven years.
In the twenty seven years there had been but three winter
floods. In no winter of the twenty seven had there been two
 winter floods. It was not probable, then, that there would be
any winter flood to enlarge the cut made by us, and without
doubt, as it seemed to us, we would be able to close the cut,
before the approach of the summer flood, by the same means
that we had used in closing the cut for three successive years
around the Chaffey gate at the head of the canal.[9] During
this winter of 1905, however, we had more than one winter
flood. The first flood came, I believe, about the first of
February, but did not enlarge the lower intake. On the
contrary, it caused such a silt deposit in the lower intake that I
found it necessary, after the flood had passed, to put the
dredge through in order to deepen the channel sufficiently to
allow water to come into the valley for the use of the people.
This was followed shortly by another heavy flood that did not
erode the banks of the intake, but, on the contrary, the same
as the first, caused a deposit of silt and a necessary dredging.
We were not alarmed by these floods, as it was still very early
in the season. No damage had been done by them, and we
still believed that there would be no difficulty in closing the
intake before the approach of the summer flood, which was
the only one we feared. However, the first two floods were
followed by a third, coming sometime in March, and this was
sufficient notice to us that we were up against a very unusual
season, something unknown in the history of the river as far
back as we were able to reach; and as it was now
approaching the season of the year when we might
reasonably expect the river surface to remain at an elevation
that would allow sufficient water for the uses of the Valley to
be gotten through the upper intake, we decided to close the
lower.” (“Born of the Desert,” by C. R. Rockwood, Calexico
Chronicle, May 1909.)
At the time when the first attempt to close the intake was made,
the cutting was about sixty feet wide. A dam of piles, brush and
sandbags was thrown across it in March 1905, but it had hardly been
completed when another flood came down the Colorado and swept it
away. A second dam of the same kind, built a few weeks later,
shared the same fate. By the middle of June, the river was
discharging 90,000 cubic feet of water per second; the width of the
lower intake had increased from sixty feet to one hundred and sixty;
water was overflowing the banks of the main canal and accumulating
in the deepest part of the Sink; and a new Salton Sea was in process
of formation.

Lower Intake at Time of Southern Pacific Loan

 Such was the state of affairs when Mr. Harriman and the Southern
Pacific Railroad Company first became directly interested in the
problem of river control. Early in 1905, the California Development
Co., finding itself in pecuniary difficulties, applied to Mr. Julius
Kruttschnitt, General Manager of the Southern Pacific, for a loan, on
the alleged ground that the Imperial Valley was furnishing a great
deal of traffic to the railroad, and the irrigation company was
therefore warranted in asking for financial assistance. Mr.
Kruttschnitt, however, declined to consider the application. The
petitioners then addressed the President of the railroad company,
Mr. E. H. Harriman, who, it was thought, might be induced to give the
necessary aid, even though he had no personal interest in the Valley
and no connection whatever with the California Development Co. Mr.
Harriman, as a man of imagination and far-seeing vision, was
naturally in sympathy with the bold attempt to irrigate and reclaim the
arid lands of the Colorado Desert, and when the matter of the loan
was presented to him, he not only gave it immediate consideration,
but ordered an investigation and a report. He finally consented,
against the advice of Mr. Kruttschnitt and other counsellors, to loan
the Development Company $200,000, “to be used in paying off
certain of its floating indebtedness and in completing and perfecting
its canal system.” Inasmuch, however, as the financial management
of the irrigation company had not always been judicious, Mr.
Harriman and the Southern Pacific stipulated that they should have
the right to select three of its directors, one of whom should be
president, and that fifty one per cent of its stock (6300 shares)
should be placed in the hands of a trustee as collateral security for
the loan. This stipulation was agreed to, and on the 20th of June
1905, the Southern Pacific Company, as chief creditor, took
temporary control of the California Development Company by
selecting three of its directors, and by appointing as its president Mr.
Epes Randolph, of Tucson, who was then acting also as president of
the Harriman Lines in Arizona and Mexico.[10]
When Mr. Harriman and the Southern Pacific thus took over the
management of the California Development Company, they had no
intention of assuming its responsibilities, directing its engineering