HESI LDS ss
The nurse is planning care for four postoperative clients each with a different drainage system. Which information, received in report requires immediate follow up intervention by the nurse?
40 ml per hour of dark cloudy urine from urinary catheter in last 4 hours
Which client requires the most immediate intervention by the nurse? a. A pregnant client with hyperemesis gravidarum who is receiving an infusion of ringer's lactate. b. an older adult receiving enteral feeding via feeding tube who has a temperature of 100.6 . C. yound adult who experienced heart stroke and is receiving a NS IV fluid bolus. d. A client with acute kidney injury who is somnolent and does not respond to verbal commands
A client with acute kidney injury who is somnolent and does not respond to verbal commands
5. A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. the client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
Ask the family to identify a specific spokesperson
A home health aid caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. What should the nurse instruct to do?
Assist the client to drink warm prune juice
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse
Advise to weigh all possible outcomes prior to the decision
4. Following a six-week refresher course, the female nurse who has been out of the workforce for 10 years is assigned to the medical unit for orientation. After the first week of orientation the charge nurse notes that the she is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take? A. talk to the orientee and ask her if she has considered working in a less stressful environment B. assign the orientee to work with a practical nurse who is a long time, efficient employee C. Inform the supervisor that for the client safety this nurse should be assigned to a slower-paced unit D. Wait until the end of the second week to see if the orientee is able to complete her assignment
B. assign the orientee to work with a practical nurse who is a long time, efficient employee
the registered nurse is gathering supplied to assist a healthcare provider with a bedside thoracentesis when the emergency nurse calls to report on a client with unstable angina that must be admitted immediately. a practical nurse pn and unlicensed as uap are available to assist the rn how would the rn assign the necessary nursing actions. a. assign the pn to assist with the thoracentesis while the nurse obtains report and the uap prepares the room for the new admission. b. assign the uap to prepare the room while the pn obtains report on the new admission and the rn assist with the thoracetesis. c. assign the uap to assist with the thoracetese while the pn goes to the ed transport the client to the unit and the rn obtain. d. assign the pn to to the ed to obtain report and transport the client while the uap preparted the room and the rn assists with
assign the pn to assist with the thoracentesis while the nurse obtains report and the uap prepares the room for the new admission.
the charge nurse is making client assignents in the intensive care department the healthcare team consistes of one nurse one nurse with 5 years experience and a new graduate nurse who just complete a 12 week intership which client should new graduate nurse. a. a client with nutisystem failure secondary to a motor vehicle collision. b. a client with chest tubes secondary to q stab would to the chest. c. a client in end stage liver failure who is experiencing esophargeal bleeding. d. a client with adult respiratory distress syndrome who is on a ventilaton
b. A client with chest tubes secondary to a stab wound to the chest.
A male client is admitted with difficulty breathing related to diagnoses of metastatic lung cancer. He tells the nurse that he does not want to be "hooked up to any machines." His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mmHg, respiratory rate 30 breaths/minute, and oxygen saturation rate is 88%. Which action should the nurse take? a. Obtain the client's legal record for power of attorney. b. Ask the palliative care team to speak with the client. c. Discontinue the IV. d. give analgesic medication as needed
b. Ask the palliative care team to speak with the client.
the charge nusre observes that an adult is vomitting after his first chemotherapy treatment and the primary nurse is prepare prescribed dose of intravenous promethazine by first diluting the medication what action should the charge nusre take. a. demonstrate how to adminster the medication without need for dilution. b. confirm that adequate dilution is necessary to reduce irritaion to the vein. c. encourage rapid medication adminstration for immediate relief dor the client. d. assume respinsibilly for the client so the medication will be give safety.
b. confirm that adequate dilution is necessary to reduce irritaion to the vein
it is most important for the charge nurse to schedule a multi disciplinary team meeting to discuss which client glucose reference rang 74 to 106 mg/dl ( 4.1 to 5.9 mmol/L) a. a women who is pregnant with twins and whose due date is one week away. b. a business executive admitted with gullain barre syndrome who has residual bilateral numbness in the lower extremities. c. an elderly client admitted throught the emergency department with a broken hip whose blood glucose is 400 mg/dl (22 mmol/l.) d. a 2 year old contracted hepatitis a while at a local daycare center
c. an elderly client admitted throught the emergency department with a broken hip whose blood glucose is 400 mg/dl (22 mmol/l.)
a charge nurse agrees to cover another nurse assigment during a lunch break based on the status report provided by the lunch which should be checked first by the charge nurse. a. the client post triple coronary bypass four days ago who has seronsanguinous drainage in on e chest tube. b. the client with an ileal conduit creared two days ago with a scant amount of blood in the drainage pouch. c. the client with a pneumothorax secondary to a gunshot wound with a current oulse oximeter reading of 90%. d. the client admitted yesterdey with a diabethic ktoacidosis whose blood glucose level is now 195 mg/dl 10.8 nmmo
c. the client with a pneumothorax secondary to a gunshot wound with a current oulse oximeter reading of 90%.
a postoperative client's respiratory rate decreased from 14 breaths/ min to 6 breaths/min after administration of an opioid analgesic. Thirty minute later, the client's respiratory rate decrease to 4 breath/ min and the nurse caring for patient the client notified the healthcare provider and administer a dose of IV naloxone. The charged nurse should counsel the nurse regarding which intervention? a. the documentation of the client's respiratory rate. b. the initial administration of the analgesic. c. the decision regarding when to call the healthcare provider. d. the administration of naloxone via Iv
c. the decision regarding when to call the healthcare provider.
the unlincesed assistive peronnel uap reposrt to the nurse that male client with fluid volume overload will not allow the ua weight which action should the nurse implement. a. direct uap to delay weighihng the client until later. b. instruct uap to weight the client using a bed scale. c. document that the client refused daily weight. d. ask the client why he does not want to be weighted
d. ask the client why he does not want to be weighted
42. four client are scheduled to recieve iv infusion but there are only three intravenous iv pump which prescribed infusion can be administered without an iv infusion pump. a. heparin in normal saline prescribed for deep vein thrombosis. b. cefriaxone in 5% destrose in water prescribed for pneumonia. c. magnesium in normal saline prescribed for hypomagnesemia. d. regular insulin in normal saline prescribed for ketoacidosis
d. regular insulin in normal saline prescribed for ketoacidosis
a staff nurse has been tardy for morning shilf assignment for the past three days and provides no explanation for the nurse manager to use when addressing this staff member tardiness. a. have the nurse sign a copy of the hospital employee attendance policy. b. caution the nurse that one more tardiness will result in probational employment. c. offer to switch the nurse shift assignments to afternoons or evening. d. stress the expectation that the nurse will arrive on time for all scheduled shift
d. stress the expectation that the nurse will arrive on time for all scheduled shift
a newly hired unlicensed assistive peronnel uap expressed fear to the charge nurse about collecting a sputum speciment form positive. which action should the charge nusre take. a. provided the uap with the infection control policy. b. offer to assist the uap with the collection of the specimen c. determine the up knowledge about hiv transmission. d. demonstrate the proper use peronal protective equipemnt
determine the up knowledge about hiv transmission.
the heathcare provider prescribes an oral medication to be given daily for 3 days However, medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?. a. evaluate the client for sysmptom of a drug interaction. b. review the medication transcription with the nurse. c. inform the pharmacist who dispensed the mdecation. d. report the medication error to the nursing supervisor
evaluate the client for sysmptom of a drug interaction.
In assigning client care to a RN and a PN, it is most important to assign which client to the RN? The client who
is exhibiting signs of Addison's crisis after corticosteroids were discontinued
the charge nurse is making assignment for a 15 bed skilled nursing unit with the staff of one nurse two practical nurse PN and two assistive personnel uap which client should be assigned to the pn. a. the client who is in end stage alzheimer who required feeding and is waiting for a long term facility placement. b. the client who bad bilateral above knee amputation nos has a sacral decubitus skin flap and is receiving vancomycin intravenously. c. the client who has right hemiplegia as thhe result of a cerebral vascular accident and receives continuouse gastrostomy feeding per enteral. d. the client who has pneumonia following a total knee replacement and is receiving clarithromycin orally
the client who bad bilateral above knee amputation nos has a sacral decubitus skin flap and is receiving vancomycin intravenously.
In evaluating a staff nurse who demonstrates inconsistent performance, which intervention should the nurse-manager employ? a. emphasize the nurse's area of weakness in light of the inconsistent performance observed and discuss how to improve in each of these area. B. focus on the strengths of the staff unit, discuss any weakness verbally but avoid documenting the nurse's negative behaviors. c. Focus on discussing how the inconsistency in the staff nurse's performance disrupts the rounding of all the the staff members on the unite. D. evaluate the nurse's performance using standards of practic, citing both strengths and weaknesses with emphasis on ways to improve practice
D. evaluate the nurse's performance using standards of practic, citing both strengths and weaknesses with emphasis on ways to improve practice
After implementation of new policies related to client identification prior to medication administration, the frequency of medication errors remains unchanged, Which should be the nurse manager's next action?
EXAMINE MEDICATION ADMINISTRATION DATA TO DETERMINE USE OF NEW POLICY BY NURSING STAFF
8. An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. What action is most important for the nurse to take?
Give detailed report to accepting nurse
A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
How many departments can use this equipment?
After making rounds, the nurse informs the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. The nurse obtains verbal prescriptions for an antiemetic, an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes. After reading back the prescriptions to the healthcare provider, which intervention is most important for the nurse to implement?
Initiate telemetry and assess the clients cardiac rhythm
what emergency room client which client should the nurse assent first. a. a female client with service right lower abdomen pain who is febrile and vomiting. b. an elderly cilent with peripheral vascular disease who is complaining of server leg pain when ambulating. c. a chile whos has a cold for two days and now is coughing up green sputum. d. a male adolcent who has been vomting for the past 12 hours and describes himself as very weak
a. a female client with service right lower abdomen pain who is febrile and vomiting.
an older client who had a hermina repair 12 hours ago suddenly becomes agitated pulls out the intravenous iv catheter and corridor demanding to be set free the nurse assiste the client back to bed and reestablished the iv access which intervention is the nurse to implement priot to leaving the client room. a. determine if the client is manifesting other neurologic changes. b. apply a restraining deivce to prevent the client from self injury. c. request family memebers report when the client is left alone. d. discuss with the family about pricing the client in a skilled care facily
a. determine if the client is manifesting other neurologic changes.
the charge nurse in an emergency center is planning client care assignments for the staff which action may be safety delegated pn. a. establish blood pressure parameters for client monitoring. b. provide client with resources and discharge teaching. c. reinforce client teaching for discharge to home. d. educate the clients about prescribed dietary charges.
a. establish blood pressure parameters for client monitoring.
A nurse who works in a long-term care facility is delegating aspects of client care to UAP. Which assignment the nurse delegate? (select all that apply) a. give mouth care to an elderly client who has a tracheostomy. b. Perform foot care including toenail trimming and heel care. c. Empty the ostomy bag for a client with a temporary colostomy. d. Identify locations of skin lesion on a newly admitted client. e. Provide a complete bed bath for comatose client
a. give mouth care to an elderly client who has a tracheostomy. b. Perform foot care including toenail trimming and heel care. c. Empty the ostomy bag for a client with a temporary colostomy. e. Provide a complete bed bath for comatose client
the practical nurse reports that a client with. deep vein thrombosis dvt was miswtakely given haparin in addition to the priority action should the nurse take. a. notify the healthcare provider. b. complete an adverse occurrence report. c. monitor for signs of bleeding. d. obtain blood for coagulation studies
a. notify the healthcare provider.
the charge nurse is assigning care to clients who are receiving continuouse intravenuous medication infustion the client receiving infustion is best to assign to licensed pratical nurse pn rather than an rn . a. octreotide acetate an antidiarrheal agent. b. methoreacate an antimeabolite chemotherapeutic agent. c. amiodarone hydronchlorinde an antiarrythi=mic agnet. d. nitroprusside sodium an antihypertensice.
a. octreotide acetate an antidiarrheal agent.
The practical nurse is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client? a. Keep mucous membranes moist. b. Maintain high Fowler's position. c. Record client's daily weight. d. Report any change in urine color
Keep mucous membranes moist.
An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family?
Managed care providers have mandatory pre-certification for hospitalization.
.The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (P) and an unlicensed assistive personal (UAP). Which activity should the nurse assign to the PN?
Measure preoperative clients for elastic shocking size
A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?
Notify HCP of client's lack of understanding
An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?
OBTAIN A DO NOT RESUSCITATE PRESCRIPTION
A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which tasks should the nurse to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Offer high caloric foods such as milk and ice cream Maintain a clean and pleasant environment during meals Assist the client with eating small frequent high calorie meals Set up the food and drink containers within easy reach
A man expressess concern to the nurse about the care his elderly mother is receiving while hospitalized. He is believed that the staff is disrespect uncaring and askes the nurse what type of care he should expect from a public hospital. Which action should the nurse take? a. Obtained detailed information about exact situation and prepare to reprimand the staff member involved. b. refer the son to the client right in the national Affordable care act as a resource for the client care expectation. c. Explain how the HIPPA is used to track client problem. d. Offer to ask the unit supervisor or client advocate to visit with the son and his mother about their concerns
Offer to ask the unit supervisor or client advocate to visit with the son and his mother about their concerns
during an evening shift on a medical unit the only nurse on the unit is busy with an unstable client . the unit clerk who is also both a medication aide and unlicensed assistive personnel (UAP) report to the nurse that a healthcare provider is on the telephone and prescribe an s needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. which instruction should be the unit clerk? a. be sure to write down what is prescribed and then repeat it back to the healthcare provider. b. ask the healthcare provider to remain on hold until the nurse can confirm the prescription. c. tell the healthcare provider the nurse will return the phone call as soon as possible. d. remain with this client and monitor the vital signs while the nurse takes the call
ask the healthcare provider to remain on hold until the nurse can confirm the prescription.
The nurse is caring for a group of five clients with the assistance of an experienced and capable unlicensed assistive personnel (UAP). Which nursing actions can the nurse delegate to the UP? (Select all that apply.)
- POST OP VITAL SIGNS for client one day after knee arthroplasty - HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION
a chile admitted to the pediatric unit being diagnosen with pertussis the nurse aberver an unlincensed pair of glove before entering the room to give the child a popsicle which action should the nurse take. a. instruct the uap to notify the nurse of any change in the client repiratoty status. b. remind the uap to apply a fitted resporator make before enterting the client room. c. assign the uap to provide care for another client and ssume full care of the client. d. review the need for the uap mto wear a face mask while in close contract with the client
Review the need for the UAP to wear a face mask while in close contact with the client.
2. The charge nurse, along with one nurse, two practical nurses (PN), a unit secretary, and two unlicensed assistive personal (UAP), is caring for 24 clients on a medical surgical unit. Which task is best for the charge nurse to assign to the nurse?
The insertion of a foley catheter for a client diagnosed with septicemia
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
UAP IS ASSIGNED TO CHECK A CLIENT FOR FECAL IMPACTION
