Leadership HESI Questions

A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement made by the client meets the self-actualization need? - "I need help because I am having trouble breathing properly" - "I cannot afford health care because I am homeless" - "People always tend to criticize me, even if I do something good" - "I want to live because I want to be a good parent to my kids"

- "I want to live because I want to be a good parent to my kid" (Self-actualization is the highest expression of ones individual potential. When a client says they want to live this indicates a need for self-actualization)

During an interview for the position of manager in the health care industry, the candidate is asked about the important qualities of a successful manager. Which response would be appropriate? (SATA) - A successful manager should take risks - A successful manager should tolerate uncertainty - A successful manager should show willingness to lead and follow peers - A successful manager should experiment with ideas for a unique situation - A successful manager should exert power for communication through different channels

- A successful manager should take risks - A successful manager should tolerate uncertainty - A successful manager should experiment with ideas for a unique situation

The nurse would consider which disaster management plan to be most applicable if an earthquake hits a metropolitan area, causing death and injuries? - recruitment of additional healthcare personnel - evacuation and relocation from the disaster site - activation of the facilities emergency management plan - collaboration of multiple agencies and health care facilities - Development of policies and procedures for managing these events

- Activation of the facility's emergency management plan - Collaboration of multiple agencies and healthcare facilities

Which actions should be completed by the manager of a group of nursing case managers? (SATA) - Study the current licensed to unlicensed staffing ration - Discuss revision of position descriptions for cross trained staff - Analyze status of clients movements through clinical pathways - Match clinical pathway actions with expected diagnostic related grouping activities - Coordinating communication among all departments in the organization

- Analyze status of clients movement through clinical pathways - Match clinical pathway actions with expected diagnostic related grouping activities - Coordinate communication among all departments in the organization

Which factor is known to threaten the nurses ability to triage and prioritize client care accurately? - a caring ethic - a biased approach to care - the shift that is being worked - the specific number of years of job experience

- a biased approach to care

A nurse manager determines which nurses on the unit will care for patients for the upcoming shift. Which element of the health care system is the manager practicing? - Delegation - Leadership - Supervision - Assignment

- Assignment

Which hospital department plays a primary role in disaster preparedness? - medical department - surgical department - emergency department - mental health department

- Emergency department

What are the responsibilities of the nurse as a leader? (SATA) - being accountable for financial matters - encouraging the direct care nurses to provide input into decisions - Identifying charge nurses who have a potential to become managers - being responsible for the selection, hiring and orientation of employees - ensuring the day to day activities of the staff are correctly planned and executed

- Encouraging the direct care nurses to provide input into decisions - ensuring that day to day activities of the staff are correctly planned and executed

The nurse manager is delegating tasks to the healthcare team to care for a client who underwent brain surgery. Which individuals on the team share accountability during delegation? (SATA) - attendant - nurse manager - certified tech - healthcare provider - UAP

- Health care provider - nurse manager

Which action makes a nurse manager also a leader? - implementing best management skills when hiring employees - having financial accountability associated with the organization - screening effectively to select the right employees for the organization - helping employees reach the highest level of their potential excellence

- Helping employees reach the highest level of their potential excellence

In a mass casualty situation, which is the facility-level organizational model for disaster management used by hospital or long term care facilities? - Emergency operations center (EOC) - Hospital incident command system (HICS) - National incident management system (NIMS) - Federal Emergency Management Agency (FEMA)

- Hospital incident command system (HICS)

The nurse is caring for a surgical client who develops a wound infection during a hospital stay. How is this type of infection classified? - primary - secondary - superinfection - nosocomial

- nosocomial

Which statement made by a nurse indicates a need for better understanding regarding assisted suicide? - " I will have an open attitude toward my client's end of life decisions" - "my participation in assisted suicide violates the nurse code of ethics" - "I will listen to my clients expressions of fear and to attempt to control my clients pain" - "I can legally participate in assisted suicide if my client made an oral and written request"

- I can legally participate in assisted suicide if my client made an oral and written request

Several individuals who sustained urgent but nonemergent injuries are seated in the ED when an ambulance arrives with a client suspected of having an MI. The nurse must explain to the waiting clients that they will have to wait longer for care. Which explanation should the nurse give? - we will be busy for a while. Unfortunately we have to take care of this other client first - I recognize that you have been waiting for a while but it now looks like you have to wait even longer - there is going to be an additional delay. the client who just arrived had a heart attack and needs to be seen first - I know you have been waiting, but a clients life depends on immediate treatment. you will receive the same attention when you are seen

- I know you have been waiting, but a clients life depends on immediate treatment. you will receive the same attention when you are seen

An RN is teaching a student nurse about the role of nurses in case of a fire in the hospital. Which statement made by the student nurse indicates ineffective learning? - I will continue O2 fir all clients, even those can breathe without it - I will seek to put out the fire by closing doors and windows and use an ABC extinguisher - I will manually maintain the respiratory status for clients on life support until they are removed from the fire area - I will take the help of staff members to move bedridden clients on blankets or carry them from the fire area

- I will continue O2 for all clients, even those who can breathe without it

The nurse leader suffers from headaches, HTN and GI probelms. Which affirmative statement by the leader reflects an appropriate way to manage stress? - I will avoid protein - I will plan a vacation - I will get enough sleep - I will participate in support groups

- I will get enough sleep

Which healthcare team member would the RN state is most suitable to provide oral medication to a client? - nurse manager - patient care tech - LPN -UAP

- LPN

An RN teaches a student about delegation. Which statement made by the student nurse indicates appropriate learning? - LPNs are accountable for the tasks they preform - complete client care can be delegated to the LPN - professional aspects of care can be carefully delegated to the LPN - LPNs can be expected to perform tasks with which they have experience

- LPNs can be expected to perform tasks with which they have experience

The count of hydrocodone is incorrect. After several mins of searching the medication cart and medication records, no explanation is found. Who should the primary nurse notify about the discrepancy? - nursing unit manager - hospital administrator - quality control manager - healthcare provider prescribing the med

- Nursing unit manager

Case management is being implemented in a major city hospital. What should the manager include when instructing the nursing staff about this care delivery method? (SATA) - The case manager advocates for the client and family - The case manager identifies outcomes and coordinates care activities - Case managers help control the costs for high-risk, high cost client populations - Identifying tasks that can be performed by other care providers is just one activity - Case management includes the client, family and all health care provider involvement

- The case manager advocates for the client and family - Case managers help control the costs for high-risk, high-cost client populations - Case management includes the client, family and all health care involvement

A nursing student is listing the nursing manager's role in the hospital setting. Which roles listed by the nursing student are accurate? (SATA) - The nursing manager coordinates the activities of the nursing staff in delivering nursing care - The nursing manager uses appropriate leadership styles to create a nursing environment for clients and staff - The nursing manager investigates ways to improve nursing care and further define and expand the scope of nursing practice - The nursing manager establishes an environment for collaborative care to provide safe and quality care with a positive client outcome - The nursing manager provides independent care to women during pregnancy, labor and delivery and also provides care to the newborn

- The nursing manager coordinates the activities of the nursing staff in delivering nursing care - The nursing manager uses appropriate leadership styles to create a nursing environment for clients and staff - The nursing manager establishes an environment for collaborative care to provide safe and quality care with a positive client outcome

What must triage nurses employ when prioritizing care with any model? (SATA) - a caring ethic - intensive care experience - a systemic approach to care - a baccalaureate degree in nursing - solid clinical decision making skills

- a caring ethic - systemic approach to care - solid clinical decision making skills

What must triage nurses employ when prioritizing care with any model? - a caring ethic - intensive care experience - a systematic approach to care - a BSN in nursing - solid clinical decision making skills

- a caring ethic - systemic approach to care - solid clinical decisions making skills

Which situation is an accurate instance of false imprisonment? - a nurse applies restraints to a conscious client to feed him or her - a nurse applies restraints to an an aggressive client after obtaining a signed consent form - a nurse applies restraints to an unconscious client who is in danger os sustaining a fall - a nurse applies restraints to a client after obtaining an order from the PCP

- a nurse applies restraints to a conscious client to feed him or her

A nurse preparing to apply restraints to a client should understand which of the following principles? - the law prohibits restraining clients until a written prescription is obtained - A felony charge may be leveled against nurses who use any kind of restraints - nurses are not obligated to report institutions that use restraints unlawfully - A nurse can be charged with assault and battery for using restraints improperly

- a nurse can be charged with assault and battery for using restraints improperly

Which of the following legal defenses are the most important for a nurse to develop? - dedication - certification - assertiveness - accountability

- accountability

A nurse is counseling a client with ALS about management of the disorder. What important suggestion should the nurse make to the client? - eye surgery may improve your vision - activities should be spaced throughout the day - opioids may be necessary for the pains in your legs - leg restraints will decrease the chance of physical injury

- activities should be spaced throughout the day

A nurse is caring for a client in post-op recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? - administer O2 as prescribed - notify the HCP - assist with insertion of chest tube - continue to assess clients respiratory status

- administer O2 as prescribed

Which system would the nurse expect to determine the number of casualties of a particular acuity level a hospital can safely accept from the incident scene in a disaster situation? - disaster triage tracking system - automated tracking system - hospital incident command system - national incident management system

- automated tracking system

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be preformed? (SATA) - airway - breathing - circulation - give comfort measures - facilitate family presence - exposure or environmental control

- airway - breathing - circulation - exposure or environmental control

The nurse is caring for a client with injuries from a bomb blast. Which emergency assessments are preformed by the nurse in a primary survey? (SATA) - airway - breathing - circulation - focused adjuncts - identify deformities - give comfort measures

- airway - breathing - circulation - identify deformities

Before a treatment requiring informed consent can be performed, what information must the client be given? (SATA) - cost of treatment - alternative treatment options - the risks and benefits of the treatment - the risks involved in refusing the treatment - the nature of the problem requiring the treatment

- alternative treatment options - the risks and benefits of the treatment - the risks involved in refusing the treatment - the nature of the problem requiring the treatment

What is the function of the medical command physician with respect to the emergency preparedness and response plan for clients after a natural disaster? (SATA) - anticipates the number of clients - checks the resource needs for clients - monitors and implements the emergency response plan - evaluates each client to determine priorities for treatment - serves as a liaison between the media and health care facility

- anticipates the number of clients - checks the resource needs for clients

A client with kidney dysfunction is about to undergo renal testing using a contrast medium. Which nursing interventions should be conducted before the procedure to ensure the clients safety? (SATA) - assessing the client for a history of cirrhosis - asking the client is he or she has a known selfish allergy - asking the client for a history of lactic acidosis - assessing the clients hydration status by checking blood pressure and respiratory rate - asking the client to discontinue metformin 12 hours before the procedure

- assess the client for a history of cirrhosis - asking the client if he or she has a known shellfish allergy - assessing the clients hydration status by checking the BP and respiratory rate

Elbow restraints have been prescribed for a confused client to keep the client from pulling out an NG tube and indwelling retention catheter. What is most important for the nurse to do? - have the prescription renewed every 48 hours - assess the clients condition per hospital protocol - provide range of motion to the clients elbows every shift - document output from the tube and catheter every two hours

- assess the clients condition per hospital protocol

The RN teaches the student nurse regarding the priority of care provided to clients with chest pain. Which activity preformed by the student nurse indicates effective learning? - placing the client in an upright position - auscultating heart and breath sounds - administering O2 via nasal cannula - assessing airway breathing and circulation

- assessing airway, breathing and circulation

An older adult client is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the clients plan of care? - ordering a vest restraint for the client to be applied at night - obtaining a prescription for a sedative so the client will sleep. better - requesting that the family provide a companion to stay with the client at night - assigning the client to a room near the nurses station for closer supervisor at night

- assigning the client a room near the nurses station for closer supervision at night

Which system would the nurse. expect to determine the number of casualties of a particular acuity level a hospital can safely accept from the incident scene in a disaster situation? - disaster triage tag system - automated tracking system - hospital incident command system - national incident management system

- automated tracking system

After a cleft lip repair a nurse places elbow restraints on the infant. The parent asks the nurse " why does sit child have the restraints?" how should the nurse respond? - they're used routinely on infants who have had lip surgery - legally we are required to put them on the infant after surgery - the staff can't be with your baby continuously to prevent touching of the mouth - because we are keeping the arms straight, your baby won't be able to touch the mouth

- because we're keeping the arms straight, your baby won't be able to touch the mouth

A med-surg unit is expecting a large volume of client admissions after a train derailment. Which member of the nursing care team will prioritize care for the unit? - charge nurse - nurse supervisor - LPN - UAP

- charge nurse

Which actions by the nurse help set the stage for a client-centered interview during the first visit after admission to the healthcare facility? (SATA) - close the door after entering the room - greet the client using their last name - open the curtains to allow plenty of light in the room - introduce oneself with a smile and explain the reason for the visit - obtain an authorization from the client after the interview

- close the door after entering the room - greet the client using their last name - introduce oneself with a smile and explain the reason for the visit

Which factor is known to hinder the ability of the triage nurse to adequately prioritize care? - lack of clinical experience - lack of baccalaureate degree - compassion fatigue - a team based approach to care

- compassion fatigue

What is the nurses responsibility when administering prescribed opioid analgesics? (SATA) - count the client respirations - document the intensity of the clients pain - withhold the medication if the client reports pruritus - verify the number of doses in the locked cabinet before administering the prescribed dose - discard the medication in the clients toilet before leaving the room if the medication is refused

- count the clients respirations - document the intensity of the clients pain - verify the number of doses in a locked cabinet before administering the prescribed dose

Which nursing action allows for a thorough assessment of a trauma client to prioritize the clients care? - avoiding manipulation of the clients limbs - asking a family member about any client drug allergies - cutting fabric that is stuck to the clients skin with scissors - auscultating heart and lung sounds through the clients clothing

- cutting fabric that is stuck to the clients skin with scissors

Which of the nurses statements are true regarding delegation? (SATA) - delegation is a complex process - delegation involves a single individual to achieve the goals - delegation involves the transfer of responsibility and accountability - delegation improves client care outcomes when used effectively - delegation includes delegatees who allocate a portion of work to others

- delegation is a complex process - delegation improves client care outcomes when used effectively

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (SATA) - guilt - denial - altruism - confusion - helplessness

- denial - confusion - helplessness

What should occur first when the last victim of a disaster has been treated in the emergency department? - deactivate the emergency response plan - conduct an administrative staff debriefing session - contact vendors to provide hospital supplies depleted by the event - determine if the needs of all organization departments have been met

- determine if the needs of all organization departments have been met

A client is admitted to the hospital with a tentative diagnosis of urinary retention related to BPH. The PCP provides notes to a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is the most important at this time? - secure a prescription for wrist restraints - orient client to time, place and person - involve family member in the clients care - determine whether any unsafe behavior patterns exist

- determine whether any unsafe behavior patterns exist

A group of clients is admitted with mass fatalities in the emergency unit. Which emergency medical service agency offers services for this condition? - medical reserve corps - hospital incident command system - Internal medical surgical response team - disaster mortuary operational response team

- disaster mortuary operational response team

A visitor says to the nurse "can I read my clients progress record? I am the sponsor from an alcohol recovery program". How should the nurse respond? - allow the visitor to review the record, sponsors have access to priviledged information - ask the PCP about granting permission to the sponsor - do not allow the sponsor to view the record - allow the visitor to review the record, clients with alcoholism need reassurance from sponsors

- do not allow the sponsor to review the record

What is the nurses specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion? - informing the clients family - monitoring pharmacologic interventions - completing a denial of rights form and forwarding it to the administrative officer - documenting both the clients behavior and the reason that specific rights were denied

- documenting both the clients behavior and the reason that specific rights were denied

A client is admitted to the hospital with a tentative diagnosis of pulmonary TB. What infection control measure should the nurse take? - don an n95 mask before entering the room - put on a permeable gown each time before entering the room - implement contact precautions and post appropriate signage - after finishing with client care, remove the gown first and then remove the gloves

- don an N95 mask before entering the room

The nurse manager asks the staff nurse to participate in creating new guidelines for providing services to the client. Which management strategy utilized by the nurse manager? - insubordination - use of expert power - empowerment of staff - management by exception

- empowerment of staff

How can the RN develop delegation and supervisory strategies to adapt to their changing roles? (SATA) - engage a nurse mentor for guidance - practice the nursing care process in various clinical settings - reinforce delegation knowledge through continuing education - become familiar with the hierarchy of authority in the health care organization - seek high quality clinical delegation experience early in their career

- engage a nurse mentor for guidance - reinforce delegation knowledge through continuing education - seek high quality clinical delegation experience early in their career

The RN is caring for a client with dysrhythmias. Which action should the nurse perform immediately according to priority? - monitoring O2 sats - establish an IV access - administer O2 via nonrebreather mask - ensure airway, breathing and circulation (ABC)

- ensure ABC's

What is considered to be the highest priority for an assault victim who presents to the ED? - monitoring the clients vitals - performing a general physical exam - ensuring the clients emotional and physical safety - counseling the client regarding STI's

- ensuring the clients emotional and physical safety

The nurse is caring for a client with breast cancer who is receiving chemo. Which action by the nurse is in accordance with the rules of the centers for medicare and medicaid services? - checks the prescription before administering meds to the client - refers the client to support systems and provides financial assistance - teaches safety measures to the client in order to prevent the risk of infection - enters symptoms and treatment provided to the client in the electronic health record

- enters symptoms and treatment provided to the client in the electronic health record

During the process of delegation, the delegator's behavior is noted to be observing and monitoring. How is the relationship between the delegator and delagatee in this situation? - limited - established - new or developing - developing or ongoing

- established

What does the nurse consider to be the center of decision-making when providing client care? - ethics of care - nursing skills - analytical skills - research based practice

- ethics of care

What qualities does the the professional nurse require to lead, manage and follow in a team? - being insensitive - impeding relationships - exercising self awareness - motivating self and others - managing emotions in self and others

- exercising self awareness - motivating self and others - managing emotions in self and others

An elderly client is admitted to the health care facility following a stroke. What should the nurse do when the clients relative who arrived much later asks to see the clients health record? - confirm the clients relationship first - ask the client's PCP - inform the nurse manager and show the records - explain that the medical health records are confidential

- explain the medical health records are confidential

A PCP prescribes airborne precautions for a client with TB. After being taught about the details of airborne precautions, the client is seen walking down the hall to get a drink. What is the most effective nursing intervention? - ensure regular visits by staff members - explore what precautions mean to the client - report the situation to the infection control nurse - reteach the concepts of airborne precautions to the client

- explore what precautions mean to the client

A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16 year old adolescent. Which should be of most concern to the nurse? - interviewing the clients parents - finding the clients sexual contacts - instructing the client about birth control measures - determining the reasons for the clients promiscuity

- finding the clients sexual contacts

A client is admitted to the emergency unit after a fire. The nurse initiates continuous cardiac monitoring and maintains oxygen saturation and end-tidal carbon dioxide. Which type of emergency assessment is being preformed? - focused adjuncts - full set of vitals - comfort measures - family presence

- focused adjuncts

Which nursing care delivery system works well in emergency situations that necessitate prioritization of care? - team nursing - primary nursing - functional nursing - patient-centered nursing

- functional nursing

The unit manager comes to work obviously intoxicated. Which action is the staff nurse ethically obligated to take? - call the security guard - tell the nurse manager to go home - have the supervisor validate the observation - offer the nurse manager a large cup of coffee

- have the supervisor validate the observation (Call the supervisor and have them confirm the suspicion and handle the situation)

A client on the psych unit is undergoing a pretreatment evaluation for ECT. Because of the clients profoundly depressed behavior, the nurse doubts the client can provide informed consent. What should the nurses initial intervention be? - consulting with the hospitals legal staff and following their recommendation - having the client verbalize the understanding and outcomes of the procedure - asking the client to sign the consent form because they have not been declared incompetent - suggesting to the primary healthcare provider that a family member sign the consent form for the client

- having the client verbalize understanding and outcomes of the procedure ( The clients understanding should be assessed first. Depressed clients are often cognitively stable and capable of providing legal consent)

Which nursing intervention can help a terminally ill client cope with feelings related to death? (SATA) - providing medications and therapies for pain management - teaching the client about the importance of complementary medicine - helping the client to find meaning and purpose in life by listening to their concerns - allow time for religious readings, spiritual visitations or attendance at religious service - encourage the client to pray if he or she wishes by facilitating privacy and a proper environment

- helping the client to find meaning and purpose in life by listening to their concerns - allow time for religious readings, spiritual visitations or attendance at religious service - encourage the client to pray if he or she wishes by facilitating privacy and a proper environment

Which nursing actions are appropriate during the primary survey of the emergency assessment process (SATA) - insert an NG tube - Immobilize the cervical spine - arranging for diagnostic studies - preparing for chest tube insertion - applying direct pressure to a wound

- immobilizing the cervical spine - preparing for chest tube insertion - applying direct pressure for a wound

Which intervention is a part of the response phase of disaster planning? - stabilize the community - limiting the impact of disaster - implementing the disaster plan - evaluate the events of disaster management

- implement the disaster plan

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? - institute fall prevention/safety measures - monitor respiratory status - measure abdominal girth daily - tests stool for blood

- institute fall prevention/safety measures

What is a living will? - a document that allows registered nurses to offer special skills to the public - it is an order that directs primary healthcare providers to refrain from reviving clients - it is a written document that directs treatment according to the clients wishes, it is a case of terminal illness or condition - it is a legal document that designates a person or persons chosen by a client to make health care decisions on his/her behalf

- it is a written document that directs treatment according to the clients wishes, in case of a terminal illness or condition

A client with a history of HTN and left ventricular failure arrives for a scheduled clinic appointment and tells the nurse "my feet are killing me. These shoes got so tight". What is the nurses best initial action? - weigh the client - notify the PCP - take the clients pulse rate - listen to the clients lung sounds

- listen to the clients breath sounds

A nurse who is working on a med-surge unit relieves a call requesting information about a client who has undergone surgery. What is the best response by the nurse? - the client is not on our unit. thanks for calling - the new privacy laws prevent me from providing any client information over the phone - the client has requested that no info be given out. you'll have to call the client directly - it is against hospital policy to provide you with any info

- it is against the hospital's policy to provide you with any info

The nurse leader conducts an education session for the nursing staff regarding case management. Which statement made by the nursing staff indicates they do NOT understand the role of case management? - It increases hospital profits by providing the optimal client care - it manages the client are by managing the client care environment - it promotes the appropriate use of hospital personnel and resources - It represents that primary health prevention is managed by a single case manager

- it represents that primary health prevention is managed by a single case manager (Case management represents an interdisciplinary health care delivery system, but not the primary health prevention that is managed by a single case manager )

A client comes to the trauma center reporting that she has been raped. She is disheveled, pale and staring blankly. The nurse asks the client to describe what happened. What is the nurses rationale for doing this? - it will help the nursing staff give legal advice and provide counseling - talking about the assault will help the client see how her behavior may have led to an event - it will let the victim put the event in better perspective and help begin the resolution process - discussing the details will keep the victim from concealing the intimate happenings during the assault

- it will let the victim put the event in better perspective and help begin the resolution process

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? - shutting the clients door during the night - apply a vest restraint when the client is in bed - leaving a dim light on the clients room at night - administer the client's prescribed as needed sedative med

- leaving a dim light on in the client's room at night

Which roles require the nurse to prioritize when implementing a primary nursing model of client care? (SATA) - manager - advocate - decision maker - team leader - care coordinator

- manager - advocate - decision maker - care coordinator

The nurse leader finds that a client with severe vitamin B12 deficiency is extremely fatigued and tends to fall. Which theory does the student nurse think that the leader would find appropriate for prioritizing the need of the client? - role theory - Maslow's theory - complexity theory - situational leadership theory

- maslow's theory

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients, staff and family members? (SATA) - move bedridden clients via stretcher - place ambulatory clients in wheelchairs - turn off all sources of supplemental O2 - provide manual respiratory support to critically ill clients - close all windows and doors and use an ABC fire extinguisher

- move bedridden clients via stretcher - turn off all sources of supplemental O2 - provide manual respiratory support to critically ill clients - close all windows and doors and use an ABC fire extinguisher

The nurse is providing care to a client in the ED. Which priority actions enhance safety? (SATA) - apply restraints - notify security staff - looking for an escape route - attempting de-escalation strategies - following the hospital security plan

- notifying security staff - looking for an escape route - attempting de-escalation strategies - following the hospital security plan

A nursing student is recalling the definition of Nurse practice acts. What do the nurse practice acts do? - Nurse practice acts describe and define the legal boundaries of nursing practice within each state - nurse practice acts reflect the knowledge and skills possessed by their profession - nurse practice acts are legal requirements that describe the minimum acceptable nursing care - nurse practice acts protects individuals from losing their health insurance when changing jobs

- nurse practice acts describe and define the legal boundaries of nursing practice within each state

A client scheduled for surgery has a history of MRSA since developing an infection in a surgical site 9 months ago. The site is healed and the client reports having received antibiotics for the infection. What should the nurse do to determine if the infecting organism is still present? - notify the infection control officer - inform the operating room of the MRSA - obtain an order to culture the clients blood - call the surgeon for an infectious disease consultation

- obtain an order to culture the clients blood

Which statement is true regarding delegation? (SATA) - the delegatees are accountable for effective client care - open lines of communication must occur between delegator and delegatee - delegation occurs only when at least two people are involved in a mutual work situation - The delegation potentials are significantly lower when caregivers such as UAP's are partnered - delegation involves sharing activities with other appropriate authority to accomplish the work

- open lines of communication must occur between delegator and delegatee - delegation occurs only when at least two people are involved in mutual work situation - delegation involves sharing activities with other appropriate authority to accomplish the work

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her need. Which phase of the helping relationship is observed? - working phase - orientation phase - termination phase - preinteraction phase

- orientation phase

While caring for a client dealing with pain, the nurse assesses the health status and prioritizes his or her needs. Which phase of the helping relationship is observed? - working phase - orientation phase - termination phase - preinteraction phase

- orientation phase

A client rescued from a fire was found unconscious and having difficulty breathing. Which team should the nurse consider to be responsible for the treatment of the client? - paramedics - prehospital caregiver - emergency medical physicians - emergency medical technicians (EMT)

- paramedics

The nurse leader as a manager makes a decision regarding the method of documentation that benefits the nursing team. Which type of decision-making style does the nurse leader utilize? - Autocratic - informative - paternalistic - shared decision making

- paternalistic (The nurse manager is making a decision based on what is best for the nursing team)

An emancipated minor admitted to the healthcare setting states " I have not had proper meals since last week". Which needs should the nurse address using Maslow's hierarchy of needs? - physiological - self-actualization - safety and security - love and belonging

- physiological

After changing a dressing that was used to cover a draining wound on a client with VRE, the nurse should take which step to ensure proper disposal of the soiled dressing? - place the dressing in the bedside trash can - place the dressing in a red biohazard bag - contact environmental services to pick up the dressing - transport the dressing to the lab to be placed in the incinerator

- place the bag in a red biohazard bag

A nurse caring for a client prioritizes nursing actions on the basis of maslow's hierarchy of needs. Which activities should the nurse perform to meet the clients safety and security needs? (SATA) - providing a cold bath to reduce the clients body temp - positioning the bed in a low position and keeping the side rails up - monitoring vitals such as BP to decrease the risk of falls - observing a client who has suicidal tendencies to prevent adverse incidents - collaborating with family members to provide emotional support for the client post-surgery

- positioning the bed in a low position and keeping the side rails up - monitor the vitals such as BP to decrease the risk of falls - observe the client who has suicidal tendencies to prevent adverse incidents

What does the nurse explain to a client that a positive diagnosis for HIV is based on? - performance of high risk sexual behaviors - evidence of extreme weight loss and fever - identification of an associated opportunistic infection - positive ELISA and western blot test

- positive ELISA and western blot test

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? - prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused - prevent an adult client from getting up at night when there is insufficient staffing on the unit - maintain immobilization of a clients leg to prevent dislodging a skin graft - keep an older adult client from falling out of bed following a surgical procedure

- prevent an adult client from getting up at night when there is insufficient staffing on the unit

In the orientation phase, a nurse and client meet and get to know each other. Which actions should the nurse follow in this phase? (SATA) - prioritize the clients problems - clarifying the clients and nurses role - evaluating goal achievement with the client - taking action to meet goals set with the client - encouraging and helping the client with self-exploration

- prioritizing the clients problems - clarifying the client and nurses role

The nurse is caring for a client with trauma in the ER. Which action should the nurse perform as the highest priority? - apply dry dressing - evaluate chest expansion - provide adequate O2 supply - apply direct pressure on a bleeding site

- provide adequate O2 supply (ABC: you are providing a patent airway)

What are the best ways for a nurse to be protected legally? (SATA) - ensure that a therapeutic relationship with all clients have been established - provide care within the parameters of the state or provinces standards for nursing practice - carry at least $100,000 worth of liability insurance - document consistently and objectively - clearly document a clients non adherence to the medical regimen

- provide care within the parameters of the state or provinces standards for nursing practice - document consistently and objectively - clearly document a clients non adherence to the medical regimen

A primary healthcare provider writes a prescription of "restraints PRN" for a client who has a history of violent behavior. What is the nurses responsibility in regard to this prescription? - asking that the prescription indicate the type of restraint - recognizing that PRN prescriptions for restraints are unacceptable - implementing the restraint prescription when the client begins to act out - ensuring that the entire staff is aware of the prescription for the restraint

- recognizing that PRN prescription for restraints are unacceptable

Which client should be treated first, according to the disaster triage tagging system? - red tag - black tag - green tag - yellow tag

- red tag

A state nurse practice act does not allow an RN to suture wounds. The primary care provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? - refuse to suture the wound - follow the primary care provider instructions - agree to suture wounds in the PCP's presence - report the situation to the state board of nursing

- refuse to suture the wounds

What is the professional nurses legal responsibility regarding child abuse? - honor the request of the parent not to report the abuse - report any suspected abuse to local law enforcement - return the child to the legal parent even if he or she is suspected of abuse - provide the parents with a copy of the Childs medical record

- report any suspected abuse to law enforcement

Litigation resulting from improper restraint use in a common nursing legal issue. A nursing student is listing points related to the use of restraints. Which factor needs correction? - restraints can be used when less restrictive interventions are not successful - restraints can be used when all other alternatives have been tried and exhausted - restraints can be used only to ensure the physical safety of the resident or other residents - restraints can be used anytime without a written order from the healthcare provider

- restraints can be used anytime without a written order from the healthcare provider

A client is admitted to an emergency unit after a factory explosion. The nurse is obtaining the clients family history and checking for a medical alert bracelet. Which safety consideration is the nurse following? - client identification - injury prevention for staff - injury prevention for clients - risk for error and adverse events

- risk for error and adverse events

An RN is planning to delegate various tasks. What does the RN do to delegate appropriately? (SATA) - avoid communication with the delegatee - select an experienced nurse as a delegatee - ask open ended questions to the delegatee - provide constructive feedback to the delegatee - select a delegatee with similar strengths as that of delegator

- select an experienced nurse as a delegatee - ask open ended questions to the delegatee - provide constructive feedback to the delegatee

An ED consists of 5 nurses who take care of 30 clients. Which responsibility of the RN is most helpful in overcoming this overwhelming situation? - task behavior - span of control - sharing activities - situational leadership

- span of control

A nurse is preforming a respiratory assessment of an 8 month old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, allow and a temp of 102. What is the priority nursing action? - suction the nasopharynx so a patent airway can be maintained - starting an IV infusion to provide necessary fluids and electrolytes - calling the respiratory therapist to start preparations for O2 administration - notifying the practitioner of the fever so a prescription for an antipyretic can be issued

- suctioning the nasopharynx so a patent airway can be maintained

A nurse is conducting an initial assessment of a client with the diagnosis of paranoid schizophrenia. Which assessment is the major concern for the nurse? - continuous pacing - suspicious feelings - lack of love for parents - disregarding the feelings of others

- suspicious feelings

A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication? - allows symptom free termination of opioid addiction - switches the user from illicit opioid use to use of legal drugs - provides postoperative pain control without causing opioid dependence - counteracts the depressive effects of long term opioid use on thoracic muscles

- switches the user from illicit opioid use to use of a legal drug

What is a high priority assignment in an emergency department when a nurse is providing care for clients during a mass casualty? - resolving stock availability problems - taking inventory and restocking supplies - debriefing to promote effective coping strategies - outlining emergency expectations and arrangements

- taking inventory and restocking supplies

Which member of the healthcare team, when using the team nursing approach, is responsible for prioritizing client care? - team leader - charge nurse - LPN - UAP

- team leader

Which behavior does the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge and the delegator does not expect the relationship to be ongoing? - telling - selling - delegating - participating

- telling

When delegating a task the delegator says " please tell me how you are going to preform this task and I will share my expectations regarding how we need to communicate with each other". What can be inferred about the delegatee? - the delegatee has expertise and an established relationship with the delegator - the delegatee has limited knowledge and ability to perform the task - the delegatee has willingness and ability but the relationship is new - the delegatee has an established relationship with the delegator but a new task has been delegated

- the delegatee has willingness and ability but the relationship is new

Hospital administrators for a new facility are formulating a fire evacuation plan as part of the organizational disaster plan. Which is the best resource for the administrators to use during this process? - the life safety code - Joint commission - the centers for medicare and medicaid services - the occupational safety and health administration

- the life safety code

The RN teaches a nursing student about the implementation process of nursing. Which example does the RN use while describing indirect care interventions using his or her knowledge? - the nurse counseling a client at the time of grief - The nurse administering an IV infusion to a client - the nurse teaching the client about an appropriate nutrition plan - The management of the clients environment to prevent infections

- the management of the clients environment to prevent infection

An elderly client falls while going to the bathroom and gets injured. The nurse taking care of the client informs the HCP. What step should the nurse take to alert the risk management team? - the nurse should document the incident in the occurrence report tool - the nurse should provide info in the medical record about the occurrence - the nurse should document in the client's medical repot that an occurrence has been made - the nurse should document in the clients medical report that the PCP has been contacted

- the nurse should document the incident in the occurrence report tool

The nurse has already removed a snakebite victim to a safe area. What action should the nurse take as the next priority in this situation? - the nurse should encourage the client to rest - the nurse should remove jewelry and clothing - the nurse should take photographs of the snake - the nurse should call for immediate emergency assistance

- the nurse should encourage the client to rest ( this will help decrease the venom circulation)

There has been a fire in the hospital. How should the nurse respond to the situation? (SATA) - the nurse should move bedridden clients from the affected area - the nurse should direct ambulatory clients to walk to a safe location - The nurse should keep all clients hooked up to O2 - the nurse should seek to contain the fire by closing the doors and the windows - the nurse should ask other hospital workers only to help push the clients in wheelchairs

- the nurse should move bedridden clients from the affected area - the nurse should direct ambulatory clients to walk to a safe location - the nurse should seek to contain the fire by closing the doors and windows

What can be inferred when a professional is said to have ethical sensitivity? - the professional has the ability to recognize ethical dilemmas - the professional has the ability to take a morally correct action - the professional has the ability to justify a well-reasoned action - the professional has the ability to think critically to rank ethical obligation

- the professional has the ability to recognize ethical dilemmas

Which personnel can determine priorities for treatment in an emergency response plan? - triage officer - public information officer - medical command physician - hospital incident commander

- triage officer

How often should a healthcare facility that is Joint Commission accredited plan to test the emergency preparedness plan? - annually - twice a year - every 2 years - every 3 months

- twice a year

To reduce a fracture of the hip, a client is placed in buck traction before surgery. Because the client keeps slipping down in bed, increased counetrtraction is prescribed. What should the nurse do to increase counetrtraction? - add more weight to the traction - elevate the head of bed - use a slight trendelenburg - apply a chest restraint around the client

- use a slight trendelenburg position

What term began to be used in the 1960's to describe case management? - process control - risk management - quality improvement - utilization management

- utilization management

What should the nurse consider when obtaining an informed consent from a 17 year old adolescent? - whether they can give consent - that the client cannot make informed decisions about health care - whether the client is permitted to give voluntary consent when parents are not available - that the client probably will be unable to choose between alternatives when asked to consent

- whether the client is allowed to give consent

The emergency department charge nurse is preparing a group of medical surgical and critical care unit nurses for participation in emergency preparedness and response for casualties due to an earthquake in the nearby area. Which actions performed by these staff nurses are appropriate? (SATA) - working with ED nurses in the resuscitation setting - recommending which clients are stable for discharge - applying principles of triage to prioritize care deliveries - directing the ancillary departments to deliver supplies - identifying clients who can be transferred out of the critical care unit

- working with ED nurses in the resuscitation setting - recommending which clients are stable for discharge - identifying clients who can be transferred out of the clinical care unit

The emergency operation center is triaging a group of clients who have been injured during a major earthquake. Which healthcare personnel are required to work with the emergency operation center to organize nursing services? - supply officer - communication officer - infection control officer - trauma program manager - emergency department charge nurse

-trauma program manager - emergency department charge nurse

What type of relationship between the nurse delegator and delegatee causes the nurse delegator to use the leadership behavior of telling? - limited - established - new or developing - developing or ongoing

limited

The nurse supervisor is assessing the care delivered by nurses working in the cardiac care unit. Which findings indicate that the nurses are providing safe health care? (SATA) - the nurses exhibit good decision making skills - the nurses act within the scope of practice of their license - the nurses provide cost-effective interventions to the client - the nurses provide both curative and preventative interventions for the clients - the nurses provide interventions that have reduced the duration of hospital stays of the client

the nurses exhibit good decision making skills - the nurses act within the scope of practice of their license

Before discharge, a client with a colostomy questions the nurse about resuming prior activities. What is the nurses best response? - most sporting activities except for swimming can be resumed based on your overall physical condition - with guidance a near normal lifestyle, including complete sexual function is possible - activities of daily living should be resumed as quickly as possible to avoid depression and further dependency - after surgery, drastic changes in lifestyle must be made to accommodate the physiologic changes caused by the operation

with guidance a near normal lifestyle, including complete sexual function is possible