Leadership HESI

The charge nurse on a surgical unit is assessing the morning lab work on four clients. which client's lab finding should be reported to the HCP immediately'?

An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL and BUN of 84

When making assignments for the day, which information provided during the change of shift report is most important for the charge nurse to consider?

An elderly female client who refuses to be cared for by a male nurse

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.

The RN is gathering supplies to assist HCP with thoracentesis at the bedside when the ED nurse calls in report on a client with unstable angina. A PN and UAP are able to assist the RN. How should the RN assign the necessary tasks?

Assign PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for the new client

A home health aid caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated.

Assist the client to drink warm prune juice

Which older client should the charge nurse assign to the most experienced nurse?

A 72 year old client with type 1 diabetes who is newly diagnosed and scheduled for discharge today

A client is admitted with exacerbation of COBD and reports that it is difficult to eat due to SOB. WHich tasks should the nurse delegate to UAP? SATA A. Assist the client with eating small, frequent high calorie meals B. Offer high caloric foods such as milk and ice cream C. Consult with registered dietician about recommended nutritional needs D. Maintain a clean and pleasant environment during meals E. Set up the food and drink containers within easy reach

A, B, D, E

The nurse is assigned to care for four clients. After receiving the change of shift report, which client should the nurse assess first? A. A client with diabetes and a history of coronary artery disease who is complaining of increased SOB B. A 10 year old with sickle cell disease who has a PCA pump and is complaining of pain2-3/10 C. A 29 year old who has had CKD for the past year and had an AV fistula placed yesterday D. An older client with COPD who is experiencing SOB and who O2 sat is 88% on RA

A. A client with diabetes and a history of coronary artery disease who is complaining of increased SOB

The nurse calls the surgeon to report that a male client who has transitioned from a PCA to PO analgesic one hour ago is now complaining in a loud voice and asking for the PCA pump. The nurse explains that the client's behavior is disturbing his roommate. The client's BP has increased from 120/72 to 150/98. Which question is best to include in the recommendation component of the SBAR report the the surgeon? A. Could the behavior be a manifestation of drug seeking? B. Can the client be transferred to a private room? C. Can the PCA be initiated and prescribed for an additional 12 hours?

A. Could the behavior be a manifestation of drug seeking?

The nurse observes a PN placing a client on the right side with left leg bent in prep for lumbar puncture. Which action should the RN take? A. Demonstrate to the PN how to position the client more effectively for the procedure B. Arrange for a UAP to assist PN during procedure C. Assume care of client and reassign PN D. Acknowledge the PN has positioned the client correctly

A. Demonstrate to the PN how to position the client more effectively for the procedure

The nurse assigns a UAP to apply sequential compression devices to a client. Which instruction should the nurse include when assigning this task? A. Report changes in color in the client's feet or legs B. Check pedal pulse prior to application C. Elevate legs onto a pillow if the client reports discomfort D. Compression should start at the toes and move upward

A. Report changes in color in the client's feet or legs

The nurse manger observes that the staff nurse has used wrist restraints to help secure an elderly female to her wheel chair. What is the priority action by the nurse manager?

Advise the nurse to remove the restraints from the clients wrists

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?

One hour after the nurse administers an analgesic, the UAP reports the client refuses to turn in bed because of continued pain. Which action should the nurse take?

Asses the client's current pain level and response to the analgesic

Two clients in the ICU are assigned to an oncoming nurse at shift change. One client has pneumonia and is being mechanically ventilated and the other had a thoracotomy yesterday is is currently complaining of incisional discomfort. Which action should the nurse take next?

Assess LOC and VS for both

A nationally known management consultant, whose fee is very high, is scheduled to speak at a day long hospital education conference. The head nurses wants the information presented at the meeting to be disseminated among the staff. Which plan will be most useful in achieving this goal? A. Schedule educational leave for the staff so that all can attend the program B. Ask two staff members to attend and report what they learned to the unit staff C. Encourage the education department to schedule the program at a time convenient to all staff D. Ask that the program be offered at three different times so that all shifts can attend

B. Ask two staff members to attend and report what they learned to the unit staff

A 5 year old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement? A. Instruct the child's parents about the need for transmission precautions B. Place an isolation cart outside the room to initiate droplet precautions C. Schedule play time with the OT D. Assign the child a room near the nurses station

B. Place an isolation cart outside the room to initiate droplet precautions

When caring for an older adult with septic shock, which intervention is most important for the nurse to include in this client's plan of care? A. maintain strict I&O B. assess warmth of extremities C. Keep HOB elevated 45 degrees D. Monitor blood glucose level

B. assess warmth of extremities

An older woman with a long history of HTN is transferred from a long term care unit because of HF. She has a signed and witnessed DNR in her record. What action should the nurse take? A. Transfer client to palliative care unit for further supportive care B. Consult with hospice case manager regarding plan of care C. Confirm current resuscitation wishes with client and family D. Ask the unit supervisor to meet with the family about desired care level

C. Confirm current resuscitation wishes with client and family

An experienced PN and a UAP are working together to assist neurologically compromised clients at mealtime. Which task is best for the PN to perform? A. Feed a quadriplegic client who has difficulty chewing and swallowing B. Assist a client with an ataxic gait transfer to a wheel chair before the meal C. Measure the allowed fluid amounts for a client on strict fluid resuscitation D Explain the food choices on the meal tray to a confused client

C. Measure the allowed fluid amounts for a client on strict fluid resuscitation

The charge nurse observes that a client with an NG tube applied to low intermittent suction is drinking a glass of water immediately after the UAP left the room. Which action should the nurse take? A. Discuss the incident with the UAP at the end of the day B. Remind the client of the potential for electrolyte imbalance C. Remove the glass of water and speak to the UAP D Write an incident report and notify HCP

C. Remove the glass of water and speak to the UAP

Contact precautions are being implemented for a client with cellulitis of the right foot. The nurse observes the UAP eating candy given to her by the client's family in the client's room. What action should the nurse take? A. Add an update on the isolation protocols to the staff meeting agenda B. Send a saliva specimen form the UAP to the lab for testing C. Report the possibility of cross contamination to infection control D. Tell the UAP not to ingest anything while in the contact isolation room

C. Report the possibility of cross contamination to infection control? D. Tell the UAP not to ingest anything while in the contact isolation room?

The nurse watches the UAP bring soap, washcloths, towel and a basin into the room of a male client who had a suprapubic catheter inserted earlier that day. Which action should the nurse implement? A. Remind UAP to provide warmth and privacy when washing and drying the area around the catheter B. Encourage UAP to offer client opportunity to perform his own catheter care independently C. Tell the UAP that the nurse will perform the client's catheter care while the UAP assists with his personal care D. Advise the UAP that the client's dressing will need to be removed before cleaning around his catheter

C. Tell the UAP that the nurse will perform the client's catheter care while the UAP assists with his personal care

The nurse manager conducts regular audits of patient care medication records and notices that the amount of narcotic pain medication administer on the evening shift in post surgical unit is inconsistent. Which action should the manger take next?

Conduct a closer examination of the staff nurse's distribution of pain medication from the evening shift

The practical nurse (PN) reports to the charge nurse that the transparent dressing covering a single lumen central venous catheter inserted in the subclavian vein of a client has come loose and the insertion site is inflamed. Which action should the charge nurse implement?

Confirm the findings of the PN while securing the transparent dressing and notify the healthcare provider.

An older male client who lives alone has a history of HF and is admitted to the hospital after passing out while walking to the mailbox. The nurse notes multiple bruises in various stages of healing. He is being treated with a cardiac glycoside, diuretic, and restricted sodium diet. Which intervention is most important for the nurse to include in the client's plan of care?

Continuous EKG monitoring

It is most important to assign which client to an RN rather than a PN? A. One hour after receiving hydromorphone prescribed for pain q4h PRN, reports severe pain B. Two hours after receiving morphine for acute pain, patient's VS are BP 112/60, pulse 88 and RR 14 C. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced D. After ambulating, a post op client grimaces and reports pain 9/10

D. After ambulating, a post op client grimaces and reports pain 9/10

The nurse who is working on a post surgical ICU receives report regarding the assigned clients for the upcoming shift. Which client should she assess first? A. An older adult 2 days post op mastectomy's and has 50 mL serosanguinous fluid in JP drain B. A teenager who had a gunshot wound repair yesterday and has a quarter size dark drainage on dressing C. A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills D. An adult who has a collapsed lung related to a fall from a ladder 8 hours ago and now has 100 mL chest tube drainage

D. An adult who has a collapsed lung related to a fall from a ladder 8 hours ago and now has 100 mL chest tube drainage

Four clients are scheduled to receive IV infusions, but there are only three pumps available. Which prescribed infusion can most safely be administered without a pump? A. Regular insulin in NS prescribed for ketoacidosis B. Heparin in NS prescribed for DVT C. Magnesium in NS prescribed for hypomagnesemia D. Ceftriaxone in 5% dextrose in Water prescribed for pneumonia

D. Ceftriaxone in 5% dextrose in Water prescribed for pneumonia?

The charge nurse observes a newly employed nurse begin to administered liquid meds via the clients gastrostomy feeding tube system via the bag hanging at above delivery pump. What action should the charge nurse take? A. Advise nurse to lower bag to eye level B. Confirm the nurse checked solution compatibility C. Instruct nurse to flush the bag with sterile saline D. Direct the nurse to stop medication administration A.

D. Direct the nurse to stop medication administration

The nurse hears new UAP who is working in long term care facility calling adult residents "honey" and "dearie." Which is the best action the nurse should take? A. Role model correct approach for addressing residents B. Call a staff meeting to encourage more professional behaviors C. Ask the facility supervisor to rebuke the UAP D. Meet with the UAP to discuss respectful client care strategies

D. Meet with the UAP to discuss respectful client care strategies

The nurse supervisor sends a UAP to a medical unit to replace an absent UAP. When delegating the task of obtaining client blood glucose levels, which is important for the nurse to implement? A. Provide UAP with instructions about how to calibrate the glucometer B. Ask the UAP to document the results in the EHR C. Ask the UAP to describe the normal BL levels for fingerstick analysis D. Observe the UAP obtain a fingerstick glucose level using the glucometer

D. Observe the UAP obtain a fingerstick glucose level using the glucometer

A HCP notifies the nurse that new prescriptions have been written for a client. Which is the first action the nurse should implement? A. Collect any needed form such as labs and radiology requisitions B. Clarify the prescriptions with the unit clerk to ensure accurate transcrition C. Document the time that the provider visited the client in the nurses' notes D. Read all of the new prescriptions for the client written by the provider

D. Read all of the new prescriptions for the client written by the provider

A RN, PN and UAP are working as team to provide care for a acutely ill client requiring immediate bedside insertion of a chest tube. Which assignment is the best use of each person's skills? A. RN inserts chest tub immediately after PN cleans the skin at insertion site B. The UAP listed to breath sounds while the RN witnesses the informed consent C. The PN instructs the family about he need for chest tube insertion while the RN obtains VS D. The UAP obtains an O2 sat level while the RN reports the findings to the HCP

D. The UAP obtains an O2 sat level while the RN reports the findings to the HCP

The nurse is observing the staff provide care to a client with AIDS who was admitted yesterday with pneumocystis pneumonia. which staff scenario requires interventions by the nurse? A. Housekeeper using a bleach solution to remove spilled blood B. Lab tech wearing gloves while performing venipuncture C. PN performing handwashing when leaving the room D. UAP wearing mask to take patients blood pressure

D. UAP wearing mask to take patients blood pressure

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 complains from clients and/or their families

The nurse is inserting an indwelling catheter for a client experiencing urinary retention when a code blue is called for another client on the who unit who became unresponsive. Which action should the nurse take?

Finish the procedure

The nurse notes the toes of a clients casted leg are cold and turning blue. The HCP is notified by phone three times, but four hours after the first notification the HCP has not come to see the client who is now complaining of severe pain. Which action is most important for the nurse to take?

Have the nursing supervisor report the situation immediately to the medical chief of staff

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

A client with severe bilateral crush injuries to the lower extremities is informed by the HCP that amputation is the only option for the client to live. The client request no life saving measure to be taken. The HCP refuses to write the DNR order. Which action should the nurse take?

Initiate a review of the situation by the hospital's ethics committee

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

Instruct nursing staff to evacuate ambulatory client to the nearest fire exits?

The UAP reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

Instruct the UAP to weight the client using the bed scale

To facilitate the success of a new fall prevention program, which action should the nurse manager implement?

Involve the staff in developing interventions for the program

an older female client who was recently widowed has become increasing 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 health plan. Which information is best for the nurse to provide the family?

Managed care providers have mandatory pre certification requirements for hospitalization

Aspirin 81 mg at 0900 daily is prescribed for an older client. At 0800 the client asks for something for low back pain, but does not have a PRN order for analgesics prescribed. Which action is best for the nurse to take?

Obtain a prescription for a PRN analgesic

The charge nurse notices that a respiratory therapist who has been cross-trained to work as a phlebotomist and UAP seems to be avoiding HIV positive clients. What action should the nurse take?

Provide the employee with feedback about the observed behavior

In planning care for a group of clients, which task should the nurse delegate to the UAP?

Reinforce teaching provided by the nurse about using the call bell

The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the PN?

Remove peripheral IV catheter

The nurse manger is preparing the curricula for a class of charge nurses. A staffing formula based on which data ensures quality care and is most cost effective?

Skills of staff and client acuity

The nurse is reviewing the lab results on 4 clients on the medical unit. In addition to standard precautions, the client with which finding should also be placed on airborne precautions?

Sputum confirms MRSA

Because of budget cutbacks, a policy was established which mandates that when the census is low, nurses will be sent home. For the third time in two weeks, a nurse who has been employed at the hospital for three months is sent home immediately after arriving to work. The nurse is obviously upset and begins to cry when told to go home. Which action should the charge nurse take

Take the nurse to private place and listen to the nurse's concerns

The charge nurse assigns an experienced PN to care for a client who needs a complex dressing change. The female PN who seems anxious with difficult assignments, tells the charge nurse that she does not feel competent to perform the procedure. Which is the best way for the charge nurse to handle this situation?

Tell the PN that assistance is available if needed but she will be responsible for the patient's care

the nurse calls the surgeon about a male client who is having abdominal pain after a bowel resection. He received hydromorphone 2 hours ago and is not requesting additional pain medication. VS include temp 97.8, HR 112 bpm, RR 24, BP 98/62, which is lower than an hour ago. Client has hx of chronic A fib and take clopidogrel, which was discontinued the day before surgery. The nurse recommends that the surgeon see the client immediately for evaluation. What information makes the report complete?

The abdomen is rigid, tender to the touch and distended.

The nurse is caring for a group of clients with the help of an experienced unlicensed assistive personnel UAP . Several specimens need to be collected and sent to the lab. Which specimen collection can the nurse delegate to the UAP? SATA

Urine from indwelling catheter.Fecal drainage sample.

An experienced 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 nurse that she has excellent wound care skills. It is a busy day and a post op 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

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

After reviewing the morning lab findings for four clients, which client should the nurse follow up with first?

the BNP assay for a client with SOB after a MI increases to 1000 pg/mL