Leadership Nursing HESI

A nursing student compares the pathophysiology of submersion injury in victims of freshwater drowning and victims of saltwater drowning. Which statement made by the nursing student indicates effective learning?

"The osmotic gradient caused by the aspirated fluid causes fluid imbalances in case of submersion in both types of water."

How would the nurse arrange the healthcare members in the ranking order based on their profession?

1. Nurse Director 2.Nurse Manager 3.Registered nurse 4.Licensed vocational nurse

The emergency department nurse is called to care for a client with a snake bite. What are the nursing interventions performed by the nurse in the order of priority?

1.Moving the client to a safe area 2.Removing the client's clothing 3.Immobilizing the affected area with splint 4.Calling for emergency assistance 5.Taking photographs of the snake

After assessing a client's reports, the nurse confirms that the client has moderate hypothermia. What should be the nurse's immediate intervention? Select all that apply.

Administering heated oxygen gas Positioning the client in supine position Applying external heat with heating blankets

The nurse is reviewing the medical reports of four clients who survived an earthquake. Which client does the nurse assess first to prevent an emergency threat?

Client 3

The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP?

Client C: Monitor Wound Discharge

The nurse ensures that the client's airway is patent and that resuscitation equipment is immediately available after the client is bitten by a snake. What kind of snakebite has led to this priority intervention by the nurse?

Coral snake

A client climbing a mountain experiences symptoms of acute mountain sickness. What is the priority nursing action performed by the nurse as prehospital care?

Descend to a lower elevation

The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case?

Developing a treatment plan for client's pain

The nurse manager delegates client-care tasks to members of the health care team in the intensive care unit. Which element of the delegation may extend to direct corporate liability for the institution?

Failure of the nurse manager to delegate and supervise the task within acceptable standards

The registered nurse is teaching a client who underwent a myringotomy about the care to be taken after surgery. Which statement made by the client indicates the need for further teaching?

I can wash my hair after 2 days.

Which questions should the nurse consider to assess and ensure delegation to the right person? Select all that apply.

Is the prospective delegatee a willing and able employee? Does the delegatee have the knowledge and experience to perform the specific task safely?

The nurse is seeking a position as a clinical nurse leader in a major city hospital. What should the nurse prepare to do in order to secure this type of nursing role? Select all that apply.

Pass the certification exam. Complete a master's degree in nursing.

The nurse manager is planning to delegate tasks to Unlicensed Assistive Personnel (UAPs). What care can be delegated on a medical-surgical unit to a UAP? Select all that apply.

Performing a bed bath for a client on bed rest Assisting a client who has patient-controlled analgesia (PCA) to the bathroom

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7?

Preparing for intubation

A nurse is working an evening shift when a fire breaks out at the hospital. Which actions by the nurse are appropriate? Select all that apply.

Removing clients from immediate danger Using a wheelchair to move a bedridden client Directing ambulatory clients to walk to a safe location

The registered nurse (RN) assigns an unlicensed assistive personnel (UAP) to obtain and record the body temperature of a client with a fever. After completing the task, the delegator evaluates the work and gets clear feedback from the delegatee related to the task. Which delegation right is followed in this situation?

Right supervision

Which individual would be an appropriate member of a critical incident stress debriefing (CISD) team for a group of staff nurses? Select all that apply.

Staff nurse Physician trained in critical debriefing Advanced practice mental health nurse

Which statement about the delegatee condition is true regarding "selling"?

The delegatee has ongoing relationships; however, the task is new.

Which factor is known to threaten the nurse's ability to triage and prioritize client care accurately?

A biased approach to care

The registered nurse is caring for a client with tonic-clonic seizures. Which action should the nurse perform immediately according to priority?

Ensuring patent airway

Which behavior indicates that a nurse is functioning as a case manager?

Reviews evidence-based practice prior to identifying interventions for a client

Which statement indicates that a nurse is functioning in the role of case manager?

"Outpatient physical therapy at the time you need it is available in the facility across town."

Which order of steps would the nurse teach the client to follow while performing expansion breathing?

1. Sit in an upright position with knees slightly bent. 2. Place hands on each side of lower ribcage, just above the waist. 3.Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation. 4.Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs.

A nurse is assigned to take care of a group of clients. Which client should the nurse see first?

A 2-year-old client with diarrhea

The emergency department (ED) nurse is triaging clients. Which client should be prioritized?

A school-age client with asthma presenting with dyspnea

Which information supports the development of a critical pathway? Select all that apply.

Actions occur in steps. Client improvement is measured against criteria. Algorithms are used in the provision of client care. Care requires participation by physical and occupational therapists.

The nursing student is learning about the common causes of hypothermia. Which statements made by the nursing student demonstrate adequate knowledge about the etiology of hypothermia? Select all that apply.

Administration of blood causes hypothermia. Administration of neuromuscular blocking agents causes hypothermia.

Which actions should be completed by the manager of a group of nursing case managers? Select all that apply.

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

During a disaster response, the emergency department (ED) charge nurse is performing functions according to the healthcare facility emergency preparedness and response plan. Which interventions performed by the ED charge nurse are most appropriate? Select all that apply.

Assign a communications nurse to work with the media personnel Assign a critical care unit nurse to transfer the clients out to expand the capacity Inform the medical command physician about the need for providers with specialty training

The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel?

Assisting with personal hygiene

Which component of delegation is defined as the ability to perform duties in a specific role?

Authority

While teaching a nursing student about delegation, the registered nurse instructs the student to determine whether the delegation process is appropriate to the situation before delegating a task. Which right of delegation is the registered nurse referring to?

Circumstance

The healthcare team is caring for four clients in an emergency department. The nurse has been delegated the task to assign tags to the clients. Which client is issued the appropriate tag?

Client with major injuries- yellow tag

The triage nurse is caring for four different clients according to the five-level triage system. Arrange the clients according to priority of receiving care.

Client with severe respiratory distress Client with gynecologic disorder Client with closed extremity trauma Client with minor burns

The nurse observes that a client with sickle cell anemia and on a blood transfusion regimen has cardiac dysrhythmias due to iron overdose toxicity. Which medication is most beneficial to this client?

Deferoxamine

The nurse says to the licensed practical nurse (LPN), "I know that you can accomplish the task with dedication. Report to me the expected outcomes and approach me for further assistance if needed." Which relationship is the nurse maintaining with the LPN?

Delegating

Emergency medical service providers are triaging victims injured in a major earthquake. What is the correct order of steps involved in the community emergency response?

During a disaster such as a major earthquake, both injured and uninjured people should be removed from danger. Then the people should be triaged by healthcare professionals. After triaging, the nurses provide onsite first aid or emergency care to the victims. Then, shelters should be provided for people who lost their home and for people who are evacuated from their home for safety.

The nurse is inspecting the chest of a client with a suspected heart attack after a fire. Which order of interventions should the nurse follow?

Inspect the chest for paradoxic chest movements. Palpate the sternum, clavicles, and ribs. Auscultate breath sounds and heart sounds. Evaluate the client for rib fractures, pulmonary contusion, blunt cardiac injury, and hemothorax. Obtain a chest x-ray and 12-lead electrocardiogram (ECG).

What is the priority nursing care for the client receiving anthracycline chemotherapy?

Instructing the client to report a chronic cough and shortness of breath

The registered nurse is caring for a client admitted with sudden paralysis in the legs and an inability to walk. Which interventions made by the registered nurse (RN) indicates correct active delegation? Select all that apply.

Instructing the licensed practical nurse (LPN) to report client's vital signs Instructing the licensed practical nurse (LPN) to administer vitamin B12 injection

A client presents to the physician with a rash. The physician orders the application of a topical medication. Which healthcare team member will most likely carry out this order?

LPN

There is a severe thunderstorm where a registered nurse is working at a camp in a rural area. Which actions should the nurse perform to prevent injuries to the clients from lightning strikes? Select all that apply.

Move the clients to the nearest buildings Educate the clients to stay away from any bodies of water. Ask everyone to stay away from open windows in the building.

In a healthcare unit, there are 30 clients and the charge nurse delegates the healthcare team for providing client care. Which statements made by the delegator would indicate care responsibilities are assigned to unlicensed assistive personnel (UAP)? Select all that apply.

Note the oxygen saturation reading Check whether the client is taking fluids Ensure that the client has time for uninterrupted sleep

Which nurse would be the best to create clinical pathways for joint replacement surgeries in an environment that supports differentiated nursing practice?

Nurse with a master's degree who case managed clients in an orthopedic care center

The healthcare team is organizing a primary survey of a client. What are the priorities to assess during the breathing component? Select all that apply.

Observe for chest wall trauma. Assess breath sounds and respiratory effort

As a part of the nursing curriculum, the nursing faculty is teaching nursing students about high-quality clinical delegation experiences and has also chosen to engage the students with nursing mentors. Which skill does the nursing faculty expect the nursing students to develop via this approach?

Professional self-confidence in delegation

Which factors does the registered nurse consider in the decision to delegate process? Select all that apply.

Predictability of outcomes Complexity of the task to be performed

While caring for an 8-year-old victim of an earthquake, the nurse finds that the child has trouble sleeping, startles easily, and experiences "flashbacks" of the disaster. What is the appropriate nursing intervention in this situation?

Referring the child to a clinical psychologist

The registered nurse (RN) is caring for a client who underwent brain surgery. The registered nurse delegated the task of reinforcing ambulation to the licensed practical nurse (LPN). Who is accountable for the client's care?

Registered nurse

The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?

Removing the clothes of the client

The registered nurse finds that the delegatee is only working for half a day in the healthcare unit. Which is the most appropriate leadership style in this situation?

Telling

While caring for the victims of a flood, the nurse notices that many of the clients exhibit immersion syndrome. Which statements does the nurse know to be true about immersion syndrome in a client? Select all that apply.

The client has been immersed in cold water. The client's vagus nerve is stimulated causing dysrhythmias.

The nurse is providing treatment to a client for the leakage of a vesicant intravenous solution into the extravascular tissue via the short peripheral catheter. What is the most important nursing priority after the nurse has stopped the infusion and disconnected administration set?

The nurse should aspirate the drug from a short peripheral catheter.

There has been a fire in a healthcare facility. How should the nurse respond to the situation? Select all that apply.

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 the windows.

The nurse is treating a client for leakage of a nonvesicant intravenous (IV) solution into the extravascular tissue. In what order should the nurse treat the infiltration?

To stop infiltration via central venous catheter, the first step of the nurse will involve stopping the infusion and removing the central venous catheter after the identification of the problem. The next step would involve application of sterile dressing if weeping from the tissue occurs. The third step for the nurse is to elevate the extremity. Next, the nurse should use warm or cold compresses according to the solution infiltrated and the organization policy. The fifth step is to insert the new catheter in the opposite extremity. The nurse should then obtain the study to determine the problem causing the infiltration. The final step of the procedure would involve the nurse rating the infiltration using the INS Infiltration Scale and document the procedure.

The charge nurse is assigning client care to oncoming staff. The new nurse on the unit expresses an inability to care for the assigned client and is requesting to be reassigned. What should the delegator do in this situation?

Understand the delegatee's motivation in the situation.

The registered nurse teaches the student nurse about the care of clients with frostbite. Which priority intervention performed by the student nurse indicates effective learning?

Warming the frostbite area in water bath