Hesi Leadership Exit Exam version 1

. The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day.

REVIEW MEDICATION TRANSCRIPTION WITH THE NURSE.

The charge nurse, along with one nurse, two practical nurses (PN) , a unit secretary, and two unlicensed assistive personnel (UP), 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.

When triaging emergency room clients, which client should the nurse assess first?

FEMALE WITH SEVERE RIGHT LOWER ABDOMINAL PAIN FEBRILE AND VOMITING *Confirm

. An adult male is transferred from postanesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone C2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?

Neurovascular assessment below the fracture

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take.

Notify Healthcare Provider

The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for developing osteomyelitis?

OLDER ADULT W/OSTEOPOROSIS WHO IS BEDFAST FOLLOWING COMPRESSION FRACTURE OF THE VERTABRAE

In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?

The client who is exhibiting signs of Addison's crisis after corticosteroid were discontinued

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

While eating breakfast, a client admitted with syncope and a 2-month history of vertigo complains of dizziness. Using the standard communication tool SBAR (Situation, Background, Assessment, Recommendation), which statement is best for the nurse to provide the healthcare provider about the client's background?

The client's significant history includes atrial fibrillation and hypoglycemia.

. The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?

Assist the client to drink warm prune juice

An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous catheter, and staggers out into the corridor demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. What intervention is most important for the nurse to implement prior to leaving the client's room?

Determine if the client is manifesting other neurologic changes

An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which nurse should be responsible in coordinating the progression or this client's care through rehabilitation and discharge?

NURSE CASE MANAGER

While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement?

Investigate the reason for the call bell alarm then complete the admission assessment

A client with leukemia is hospitalized for weakness, fatique, and anemia. The client is restless and tachycardic. Which intervention is most important nurse to include in the plan of care?

MAINTAIN PROTECTIVE ISOLATION

. The nurse receives a telephone prescription from the healthcare provider for a client's persistent cough and wheezing, The prescription includes a chest xray, an antibiotic, and a nebulizer treatment now and PRN. Alter reading the prescription back to the healthcare provider to ensure accuracy, which intervention should the nurse implement first?

NEBULIZER BREATHING TREATMENT

A male practical nurse is reluctant to use new blood glucose monitoring equipment despite having attended the mandatory in service about the equipment. Which action is best for the charge nurse to take?

Observe the PN while he uses the equipment

Several experienced registered nurses are serving on a screening committee to interview prospective candidates for a nurse manager position on an acute care inpatient unit. The candidate with which characteristics is probably best for this position?

Oldest child in family; Bachelor's Degree in Nursing; played on the college volleyball team

. A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past 3 days as the result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital, Which intervention is most important for the nurse to include in this client's plan of care?

Initiate cardiac monitoring for the clients.

The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?

MUCOUS MEMBRANE MOIST

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 PRSCRIPTION

. After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-not- resuscitate instructions. Which action should the nurse take?

Provide the healthcare provider with a copy of the client's bill of rights

An unlicensed assistive personnel (UP) who is working on a skilled nursing unit is diagnosed with hepatitis A (HVA). Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, and low-grade fever. What action should the nurse-manager take next?

Refer the nurse to employee health for serological testing.

A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UP) donning on a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?

REVIEW THE NEED TO WEAR A FACE MASK WHILE IN CLOSE CONTACT.

. The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take

Respond to the code. OR Finish the procedure Not sure

. A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?

Shut all doors to client rooms and tell everyone to stay in their rooms until the fire dept arrives

A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff members tardiness?

Stress the expectation that the nurse will arrive on time for all scheduled shifts.

The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?

The acuity level of the clients on the unit.

The charge nurse is making assignments for a 15 bed skilled nursing unit with the staff of one nurse, two practical nurses (PN) and two unlicensed assistive personnel (UAP) Which client should be assigned to the nurse?

The client who had bilateral above knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously.

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?

Collect client data based on plans of care

Which client requires the most immediate intervention by the nurse?

CLIENT WITH ACUTE KIDNEY INJURY who is somnolent and does respond to verbal commands.

A newly hired unlicensed assistive personnel (UP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?

Determines UAP KNOWLEDGE ABOUT HIV TRANSMISSION.

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 HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION

A nurse who works in a long term care facility is delegating aspects of client care to UAP. which assigments should the nurse delegate?

Perform foot care including toenail trimming and heel care -Empty the ostomy bag for a client with a temporary colostomy

Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits

BE AVAILABLE TO ALL SHIFTS TO DISCUSS CHANGES IN HEALTH BENEFITS

1. The nurse is caring for an older adult who was admitted with a Urinary tract infection and is now exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative care goals should the nurse include in the plan of care? (Select all that apply)

BODY TEMP with in normal limits. REDUCE WBC count. NEGATIVE URINE CULTURE

. The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

Documented data in the clinical record before assessing client's condition.

When making assignments for residents of a long-term care facility who require assistance with FEEDING which client give to PRACTICAL NURSE and which client to licensed assistive personnel (UAP)

Client who drools, but swallows solids after many

The unlicensed assistive personnel (UP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to blain his dally weight Which action should the nurse implement?

Ask the client why he does not want to be weighed

An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100° F (37.8° C), blood pressure 98/50 mmHg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?

Assess the amount of wound drainage daily

A male client is admitted with difficulty breathing related to a recent diagnosis 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 mm, respirations 30 breaths/minute, and oxygen saturation rate is 88%. Which action should the nurse take?

Discontinue the intravenous infusion

To help prevent litigation by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will

Discuss how to handle complaints from clients and or their families

. 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

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive one of the visitors is lying on the client's bed. Which action should the nurse implement?

EXPLAIN THE CLIENT HAS THE RIGHT TO HAVE VISITOR LIE ON THE BED

. The nurse is reviewing records of clients with diabetes in a long-term care facility, The nurse notes that the pre-prandial blood glucose values, obtained during routine glucometer checks in the past 2 days, are consistently 50 to 60 mg/dL higher than those recorded in the previous 2 weeks. What action should the nurse take first?

Evaluate calibration of glucometers in use per manufacturer guidelines

A male client who recently learned that he has Huntington's disease tells the nurse that he does not want his daughter to know about the disease because she may someday want to have a child of her own. Which intervention should the nurse implement?

Explain that his daughter has a right to know of potential health problems.

. Which situation on an acute care inpatient surgical nursing unit requires intervention by the nurse-manager?

A unit clerk receives a verbal telephone prescription from an attending healthcare provider.

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

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 implement?

Advise to weigh all possible outcomes prior to the decision

It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?

An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dl.

. The charge nurse is making client assignments in the intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate

A client in end stage liver failure who is experiencing esophageal bleeding

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

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

The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?

NOTIFY THE HEALTHCARE PROVIDER OF THE CLIENTS LACK OF UNDERSTANDING

A client with a blunt trauma injury to the abdomen who underwent surgery for an emergency splenectomy is now being transferred to the intensive care unit (ICU). The post anesthesia care unit (PACU) nurse provides a bedside report to the receiving ICU nurse and reviews intravascular lines, tubes, intake, and output. Which additional information should the nurse provide to complete the report?

Peripheral pulses present with full range of motion of both legs

An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital. The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is best for the charge nurse to take?

Watch the PN perform sterile wound care to validate her skill level