HESI Management Practice test
A nurse who works in an acute minor illness clinic returns from lunch and finds several clients who need attention. Which client should the nurse attend to first?
The child who is dehydrated needs care first (C). Not knowing how long the fluid bag has been empty, the nurse should hang a new bag, see if it flows, and if not, assess for infiltration. A new IV site may have to be started.
The charge nurse, along with two registered nurses (RN), one practical nurse (PN), and one unlicensed assistive personnel (UAP), is working in an emergency department. What activity should be assigned to the UAP?
Transport a client diagnosed with septicemia to the medical unit.
Which pediatric client requires immediate intervention by the nurse?
A 4-year-old with an easily palpable bladder and frequency. Frequency and bladder distention (C) are indications of urinary retention, which requires immediate intervention by the nurse.
The charge nurse working in a long-term care facility is informed by the LPN that a client's son is unhappy with the care his mother is receiving. What action should the nurse take first?
The nurse should first obtain information about the nature of the complaint and ask the LPN to describe what he/she knows of the situation.
Which client fits the criteria for a terminal illness?
43 yo ALS pt. Terminal illness describes the client's life expectancy as less than six months without life-sustaining measures,
During report, the charge nurse informs a nurse that she must work on another unit. The nurse begins to sign deeply and tosses about her belongings as she is preparing to leave, making it known that she is very unhappy about having to "float." What is the best immediate action for the charge nurse to take? A. Continue with report, and talk to the nurse about the incident at a later time. B. Ask the nurse to call the supervisor to see if she can be reassigned. C. Stop report and remind the nurse that all the staff must "float" at some time. D. In the presence of other staff members, inform the nurse that her behavior is inappropriate.
A
The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance of a change in his diet postoperatively. What action should the nurse implement? A. Review information about dumping syndrome. B. Have the client sign another consent. C. Notify the surgeon about the client's comment. D. Explain the surgical procedure.
A
The nurse-manager is talking to a new nurse who is thinking about resigning before orientation to the unit is over. The nurse-manager explains that reality shock after graduation is common. Which explanation should the nurse-manager use to best describe reality shock to the new nurse?
A period of role adjustment from school into the work force.
The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to acquired immunodeficiency syndrome (AIDS). Which room would be best to assign to this client?
A semi-private room without a roommate (D) is the best assignment because the room can be easily blocked to create a private room should the client require isolation measures due to the pneumonia (the AIDS diagnosis alone does not affect the type of room assignment). A client with pneumonia should not be exposed to an outside air ventilation system (A). The client should not be assigned to a room with a client who is at risk for pneumonia
An emergency room anticipates an influx of injured clients from a large motor vehicle collision on a major freeway. Which client should the triage nurse send to the trauma staff for immediate intervention? A. A young adult male with a suspected closed head injury who has no respirations despite having his airway repositioned by the emergency medical team. B. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway. C. A teenager with a suspected fractured left leg whose respirations are 26 breaths/min, capillary refill <2 seconds, and who can follow simple commands. D. A young adult with a facial laceration that is controlled by pressure and whose respiratory rate, capillary refill, and ability to follow commands are all WNL.
B
The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? A. An elderly client with end-stage cirrhosis who had a liver biopsy 4 hours ago. B. A client scheduled for a femoro-popliteal bypass surgery tomorrow. C. A middle-aged client with acute pancreatitis and lower left quadrant pain. D. A female client with angina and ectopy noted on the telemetry monitor
B
The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one unlicensed assistive personnel (UAP) who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? A. 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. B. 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. C. 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. D. 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.
B
The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan? A. Do not allow those with influenza to be admitted to the unit. B. Require that all clients receive a pneumonia vaccine prior to admission. C. Ensure that sterile technique is followed when changing surgical dressings. D. Encourage clients to drink water to prevent urinary tract infections.
C
The nurse receives report in the emergency center for four clients. Which client should the nurse assess first? A. A screaming child with a compound fracture of the wrist. B. A diabetic client with a laceration on the sole of the foot. C. A client experiencing shortness of breath and dyspnea. D. A geriatric client with many new and old bruises noted.
C
The nurse is caring for 4 clients on an orthopedic floor: 2 pts with total hips, 1 pt with total knee, and 1 pt with a fractured femur who is in skeletal traction. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)?
Change the linens for the client with skeletal traction
The charge nurse assigns the care of a client with diabetes who has hyperglycemia to a practical nurse (PN). In supervising the PN, what is the charge nurse's most important action? A. Decide which sliding scale insulin dose should be administered. B. Obtain the blood sugar results via skin puncture and glucometer. C. Notify the healthcare provider of the daily serum glucose results. D. Confer with the PN about any manifestations the client is exhibiting.
D
The nurse is giving change-of-shift report for four clients in the emergency center and reports the client with the terminal disease has a living will and a "Do not resuscitate" (DNR) order on file. Which client fits the criteria for a terminal illness? A. 2-year-old child with esophageal burns from drinking drain cleaner who now has a gastrostomy tube. B. 76-year-old female client with Alzheimer's disease who is pacing the halls and trying to "go home". C. 52-year-old male client who had a partial lobectomy and on a ventilator on the 2 postoperative day. D. 43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration.
D
The registered nurse (RN) and unlicensed assisted personnel (UAP) are working together to provide care for a bedfast client needing total care, medication, and Foley catheter irrigation. How should the RN assign the client's care? A. UAP: Personal care, catheter, irrigation, I&O. RN: Medications. B. UAP: Personal care. RN: Medications, catheter irrigation, I&O. C. UAP: Catheter irrigation, I&O. RN: Medications. Both provide personal care. D. UAP: Personal care, I&O. RN: Catheter irrigation, medications.
D
The nurse is preparing assignments for the day shift. It is most important that the client with which diagnosis and description is assigned to a registered nurse?
Depression-Admitted during the night, following a suicide attempt with an overdose of Tylenol. Requires communication and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-to-one relationship with a depressed pt is beyond the scope of practice for a PN. Additionally, Tylenol is extremely hepatotoxic & careful assessment is essential-
Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?
Feed a client with minimal dysphagia. Delegation of pt care is delineated by state boards of nursing practice and include specific guidelines regarding which tasks are within the scope of practice for each level of care provider and include the components of delegation to the UAP. Feeding a pt is a basic care measure that is within the scope of practice for a UAP.
When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority?
HTN. Blood pressure control (A) has the highest priority, which is necessary to reduce cardiovascular complications and slow the progression of renal dysfunction
The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective?
Less time for nursing staff to complete the daily charting
Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital?
The case manager notifies the family that the critical pathway requires transfer to a hospice facility. *Critical pathways provide care guidelines, rather than required methods of care. The nurse should intervene in the situation described in (A) to ensure that the client and family are aware of options available.
When the charge nurse is making assignments, which tasks can be assigned to an unlicensed assistive personnel (UAP)?
Take vital signs, give a cleansing enema, and apply soft restraints to an older client.
The nurse notes a client's postoperative leg is cool with a capillary refill greater than 4 seconds and calls the healthcare provider. After 30 minutes of not receiving a return call from the healthcare provider, which action should the nurse take first?l
The HC provider may have inadvertently not received the 1st call, so Attempt to recall the same HC provider is the best action to take first. According to the Team STEPPS, 2 attempts should be made to notify the provider before proceeding through the chain of command
A female client is receiving an enteral feeding via NG tube. The daughter reports to the charge nurse that her mother is coughing vigorously and sounds congested. Which staff member should the charge nurse ask to check on the client?
The RN who is entering nursing notes (D) is working on a task that has less priority than (A).
During coronary artery bypass graft (CABG) surgery, a male client with a history of chronic tobacco abuse experiences a dramatic decrease in his oxygen saturation. Subsequently, the client remains on a ventilator two days longer than anticipated. Which factor should the nurse consider when evaluating the client's progress?
Variance- A variance is any event that may alter a pt's progress through the clinical pathway, such as remaining on a ventilator for an additional two days
