(Hesi + eaq) Practice

The nurse manager is implementing a change in evening care for clients to include back rubs to promote sleep. The nurse manager convinces the managers of various nursing units and also supports nursing staff who are willing to implement the change. Which component of Kotter's eight step model is involved in this scenario?

forming coalition

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have?

fracture of nose

A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?

interstitial

Which model of nursing care would include working "within the walls" as well as "beyond the walls" of the hospital?

nursing case-management model

A nursing assistant is working with a delegator. Which action of the nursing assistant may negatively affect client care management?

performing same task as delegator

A staff nurse states "I am sorry, I am responsible for the situation" while communicating to the nurse leader. Which communication pattern is the staff nurse using?

placation

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client?

protect skin from bile drainage

While working with a delegatee, the registered nurse says to the delegate, "It's easy; you can do the procedure tomorrow after watching me do it today. Just follow the steps I have demonstrated." What is the behavior of the registered nurse in this situation?

selling

A nurse manager receives a complaint from a client that a particular staff member had been rude when providing care. The nurse, rather than punishing the staff member, listens to his or her side of the story and then talks to the client to clarify the misunderstanding. Which leadership theory is reflected in this scenario?

situational contingency

Which theory emphasizes that leadership effectiveness depends on the executive nurse's interpersonal skills?

situational contingency

During a group therapy session one of the clients asks a client with the diagnosis of antisocial personality disorder why the client is in the hospital. What response might the nurse expect from a client with this disorder?

society makes rule for other people

The registered nurse oversees five unlicensed nursing personnel (UNP), and each UNP cares for five clients, so the registered nurse in effect has responsibility for five UNPs and 25 clients. What do these numbers of subordinate and clients indicate?

span of control

Which parental statement indicates accurate understanding of bicycle safety for the school-age client?

stay close to curb

A man walks into the emergency room (ER) with sunglasses on and tells the nurse that he fell off a ladder and hit his head and was unconscious for a few minutes. What is the most appropriate next question the nurse should ask the client?

take sunglasses off

An isolated older adult is diagnosed with cancer and fears death. Which intervention provided would help to induce relaxation and to communicate interest in the client?

touch

A nurse manager regularly analyzes herself and her performance, focusing on developing leadership qualities such as assertiveness, confidence, and task knowledge. Which leadership theory does the manager most likely subscribe to?

trait theory

What should be included in the assessment of a school health promotional program for adolescents? Select all that apply.

violence, drugs and gun safety

The nurse is caring for a client who meets the criteria for the emergency severity index level 2 (ESI-2). How soon should the client be seen by the physician?

within 10 minutes

When using the AMPLE memory aid to conduct a health history during the emergency assessment, which questions will the nurse ask? Select all that apply.

"Do you smoke or drink?" "When was your last meal?" "Do you have any drug allergies?" "When was your last tetanus shot?

Discharge planning for a client with chronic pancreatitis includes dietary teaching. Which statement indicates to the nurse that the client needs more teaching?

"I can eat foods high in fat now that the acute stage is over

At which body temperature does the blood pressure of a victim of hypothermia become obtainable only by Doppler?

91.4

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning?

"Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM.

Which questions related to decision making for delegation are appropriate according to the delegation right of "right circumstance"? Select all that apply

Are the equipment and resources available to complete the task? Does the delegatee have appropriate supervision to complete the task?

A nurse manager in a cancer care facility finds that the nursing care team is demotivated due to consecutive deaths of two terminally ill cancer clients. Which action of the nurse manager would help renew the team's energy?

Arranging a notice board in the unit and posting photos or messages reflecting achievements of the team

Following surgery, a client asks the nurse to help with measuring intake and output. What is the best nursing response?

Assess the client's ability to measure the intake and output

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?

Automated tracking system

The nurse leader performs his or her own honest appraisals on a regular basis and feels good about the job. Which rule is the nurse leader implementing by this action?

Building self-confidence

The registered nurse is teaching a student nurse about caring for clients in emergency conditions. Which client if selected by the student nurse for immediate care would indicate effective learning? Select all that apply.

Client with an active hemorrhage Client with a substernal chest pain

What does "access to care" include according to the Picker Institute's eight dimensions of patient-centered care? Select all that apply.

Clients want to be able to see a specialist when a referral is made." "Clients want to schedule appointments at convenient times without trouble." "Clients need to be able to find conveyance when travelling to different healthcare settings.

While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe?

Dealing with retirement

The first responders rescue and bring submersion victims of a natural disaster to the emergency department. Which is an appropriate intervention for treating clients with submersion injuries?

Immediately apply heating devices to keep the client's body temperature elevated

The nurse is teaching a group of nursing students about case management. What should the nurse explain as being the goal of case management?

Integrate care with cost-effective approaches

Which critical factors would the nurse say are associated with situational-contingency theory? Select all that apply.

The ability of the leader to reward followers The degree of trust and respect between leaders and followers The task structure about goals and the complexity of the problems being faced

While interacting with an older adult, the nurse leans towards the client. What does this posture convey?

The nurse is involved and interested in the interaction

A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse?

"Please go on to see your daughter. I'll bring the baby to her room."

The senior nurse advises a newly promoted nurse concerning various aspects of the leadership role. Which advice by the senior nurse would the newly promoted nurse most likely consider as leading by example?

"Try to be a participant in political activity in the local community.

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback?

"You performed that procedure safely and professionally.

Which statement of the nurse is true regarding Hersey's Situational Leadership Model?

The situational leadership model provides a solid foundation for delegation decisions.

A registered nurse (RN) delegates the task of oral care of a client with stomatitis, to an unlicensed assistive personnel (UAP). Which instruction should be given by the RN to the UAP?

"Be certain to use mouthwash containing sodium bicarbonate with the client."

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education?

"I should provide conditional positive support.

The registered nurse is teaching a nursing student who underwent training for disaster management on how to cope effectively after a disaster event. Which statements by the nursing student indicate a need for further teaching? Select all that apply.

"I will work for 15 hours per day." "I will monitor stress levels of colleagues." "I will talk about my feelings with my family.

Which among the Five Rights of Delegation is the cornerstone of delegation?

"Right communication and direction

The nursing leader stated, "The reimbursed cost is less than the full charge for a service in the hospital." Which type of health reimbursement does the nurse leader describe?

contractual allowance

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond?

decreases symptoms

Which characteristic of a manager should the nurse leader exclude while addressing the complex issues of the hospital?

Developing a vision

A 25-year-old man is admitted to the inpatient psychiatric unit. He is angry and refuses to take his prescribed medications at bedtime. He has been agitated and had several verbal altercations with other clients earlier in the evening. What is the best nursing response to this situation?

Educating him on the reasons for and benefits of taking the medication but not giving it to him if he continues to refuse the medication

A nurse leader is promoted as nurse manager of a critical care unit. Which action would demonstrate the effectiveness of the nurse leader role as a manager?

Establishing the goals considering the staff expertise

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. Which statement by the UAP would the nurse recognize as providing false reassurance?

Everything will be fine

A registered nurse is teaching a nursing student about evidence-based practice. Which statements should the nurse include in the teaching? Select all that apply.

Evidence-based practice is conducted by practicing nurses and other healthcare team members." "Institutional review board approval is not needed to implement evidence-based practice." "Evidence-based practice uses information drawn from research to determine safe and effective nursing care."

A client is admitted into the mental health unit involuntarily. What course of action should the nurse take in order to prevent legal complications?

File with the court within 96 hours of the client's initial detention

Which nursing actions indicate effective implementation of systems thinking theory principle with respect to "thinking of the Big Picture"? Select all that apply.

Focusing on the needs of all the residents in a long-term care facility Knowing about the complications of emergency department overcrowding in an urban setting

A client with colitis inquires as to whether surgery eventually will be necessary. When teaching about the disease and its treatment, what should the nurse emphasize?

For most clients, surgery is recommended only if nonsurgical treatments have been unsuccessful.

After a teaching session, the nurse evaluates the client's understanding of hypoparathyroidism. Which statement made by the client indicates the need for further education?

I should include yogurt in my diet.

A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching?

I'll have to be careful not to cut my baby's nails short."

Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client?

Increased expired carbon dioxide

In evaluating risks, what does the nurse understand is the responsibility of risk managers?

Involving perspectives from numerous disciplines

The nursing instructor is teaching a group of nursing students and describes a situation where the victims of a mass casualty event who have been exposed to radiologic dispersal devices (RDDs) are brought to the emergency department. Which statement about RDD made by a nursing student indicates effective learning?

Ionizing radiation released by an RDD does not cause immediate serious illness to people nearby.

The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client?

Licensed vocational nurse (LVN

What does the nurse leader expect all members to be doing when a therapy group is achieving its objective?

Making an effort to include one another in discussions

What are the priority care issues during chemotherapy? Select all that apply.

Managing the client's complications Protecting the client from side effects

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 this client?

Paramedics

The nurse has just arrived in the unit for her shift at the healthcare facility. There are two new clients admitted to the unit. What should the nurse do first to collect the first set of information about the clients assigned to his or her care?

Participate in the bedside rounds

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply

Providing meticulous skin care Reducing shear forces and friction avoid pressure

8. The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader?

RN

The first responders rescue and bring submersion victims of a natural disaster to the emergency department. Which is an appropriate intervention for treating clients with submersion injuries?

Stabilize or immobilize cervical spine in all near-drowning victims

The nurse is reviewing a plan of care for a client who has experienced a traumatic amputation of a leg. The nurse recognizes that which intervention listed on the plan is of lowest priority?

Teaching residual limb care

The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved?

The client expresses acceptance of health status by the day of discharge

The nursing student is learning about common chemical agents of terrorism. The nursing instructor presents a situation where the victims have burned or blistered skin and describes the agent as a brown gas that has a garlic-like odor. What statement made by the nursing student indicates effective learning?

The clients were exposed to mustard gas."

What should the nurse include in dietary teaching for a client with a colostomy

The diet should be adjusted to include foods that result in manageable stools

A nurse in the pediatric clinic is planning care for a 7-year-old boy with enuresis. What is an appropriate short-term goal for this child?

The interval between voidings will increase by 1 hour

The nurse leader teaches the student nurse about the quality assurance (QA) process. Which statement made by the student nurse indicates ineffective learning?

The major task is staff development

Which statement reflects the concept of "referent power" to the nurse?

The nurse manager hires the student nurse she advised to work in the agency after graduation.

Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice?

The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan

Which nurse is using complex critical thinking skills when caring for a client?

The nurse talks to the client to identify reasons for a particular behavior

The nurse manager assigned 5 visits per day to a home health nurse, but the weekly average of the home health nurse is 4.8 visits per day. What reason does the nurse manager expect is the cause for this discrepancy?

The time for one visit took twice the amount of time normally

The nurse manager is teaching the licensed practical nurse (LPN), the evidenced-based practice regarding the use of saline and the low-dose heparin flush solution for capped angiocatheters. Which statement by the LPN indicates they understood the teaching? Select all that apply.

The use of heparin flushes disappeared in the late 1990s." Correct3 "The use of high doses of heparin solutions is not recommended in adults."

A nurse is conducting a health campaign in a school. During the health campaign, the nurse finds that the school management has replaced the registered nurse (RN) with a trained clerk. What should the nurse, as a community opinion leader, do?

Write a letter to a local newspaper editor opposing the decision of the school board

After assigning a specific work to the unlicensed nursing professional, the registered nurse does a critical analysis of the work to determine if the actions taken were appropriate and provides a detailed explanation of what occurred. Which action related to delegation is the nurse performing?

accountability

The nurse is caring for a client on antiretroviral therapy who has Pneumocystis jiroveci pneumonia. Which action is priority?

adequate oxygenation

A newborn is found to have Down syndrome. The nurse knows that Down syndrome is usually accompanied by several problems. Which assessment should the nurse perform during the physical examination?

ardiac irregularities for congenital heart disease

What is the priority nursing action when caring for a client receiving nitroglycerin for the treatment of angina?

ask client to sit or stand slowly

A licensed practical nurse (LPN) was hired recently. Which strategy should be applied by the registered nurse (RN) to open lines of communication between them?

asking

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

authority

The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant?

basic personality

A nurse manager promotes a staff nurse to assistant manager of the medical unit as the staff nurse had expressed interest in taking on more responsibilities. Which type of ethical principle is exhibited by the nurse manager by this activity?

beneficence

he nurse is caring for the victims of a terrorist attack involving explosive devices. Which type of damage is most likely caused by a crush injury?

blunt trauma to the head

A healthcare team is caring for a postsurgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply.

changing the dressing Administration of oral analgesics Reinforcing leg exercise instructions

The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying?

confidence

The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model?

continuity of care is a problem

The nurse manager finds that there is an increased infection rate in the unit due to an increased number of client visitors. The nurse believes that a change in the visitor policy could help reduce the infection rates. The leader is initiating an open dialogue about external and internal realities among the team members. Which attribute of Kotter's eight-step model is involved in this action by the nurse manager?

creating urgency

The registered nurse (RN) delegates obtaining and recording a client's pulse every 30 minutes. During the last hour, the licensed practical nurse (LPN) fails to report the client's elevated heart rate to the RN. Which factor best explains the situation?

decayed information

The nursing student accompanies a group of registered nurses in a campaign that promotes the participation of parents to get their children immunized. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it to last year's report. Which type of research does the nursing student think that the group is doing?

evaluation research

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first?

gather more data

A client reports foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. Which client statement indicates to the nurse that further teaching is needed?

i will drink moderate alcohol

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent?

inaccurate interpretation

A 20-year-old woman comes into the clinic after missing her menstrual period 2 weeks ago and states that she suspects that she is pregnant. As the nurse is reviewing her medications, the client says that she is taking isotretinoin. What should the nurse consider regarding isotretinoin?

it is a teratogen

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. What explanation does the nurse give for why a PEG tube is preferred for administering a tube feeding?

less chance of aspiration

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

making eye contact

The nurse is assessing a client with an illness. Which questions asked by the nurse indicates that he or she is gathering a client's physical and developmental health history? Select all that apply.

marital problems and ADL's

The nurse is relating to and inspiring the client who has a psychiatric disorder to achieve the client outcomes. Which of Gardner's leadership tasks is reflected in the nurse's actions?

motivating

Which behavior of the nurse leader is characterized as delegating according to the Hersey's model?

observing or monitoring

A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis?

preventing falls

Which subdimension would form a part for the caring process "doing for" according to the Swanson's theory of caring? Select all that apply

protecting and comforting

The nurse is caring for the victims of a natural disaster who are all hypothermic. Which interventions does the nurse employ when using spontaneous rewarming? Select all that apply.

radiant lights and move to warm dry place

Which constructive aspects of conflict does the nurse leader identify? Select all that apply

releases pent up emotion Helps individuals grow personally Builds cohesiveness among people

What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)?

report blurred vision

The registered nurse assigns a task to a licensed practical nurse (LPN) to check the blood pressure and temperature of a client. Which factor is transferred to the LPN for the performance of the task?

responsibility

A nurse is evaluating a client's response to receiving an intermittent gravity flow percutaneous endoscopic gastrostomy (PEG) tube feeding. Which clinical finding indicates that the client is unable to tolerate a continuation of the feeding?

rise of formula in tube

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a laryngectomy is scheduled. What is the most important piece of equipment that the nurse should place at the client's bedside postoperatively?

suction equipment

After assigning a task, the delegator makes sure that the instructions are clear to provide feedback related to the task. Which delegation right is referred in this situation?

supervision

A newborn with acquired herpes simplex virus infection is being discharged. Which facet of development should the nurse instruct the parents to monitor closely?

visual clarity

The unlicensed nursing personnel (UNP) is delegated tasks related to client care. What is the correct order of steps the registered nurse (RN) should follow when deciding to delegate the work to the UNP?

1. Assessing the client's health status 2. Determining the knowledge and skills of the UNP 3. Assigning the client-specific tasks to the UNP 4. Monitoring the assignments allotted to the UNP 5. Reporting deviations in the client's response

What would be the level of the client with a hip fracture due to a mass disaster according to the emergency service index (ESI)?

3

The nurse is performing a newborn assessment. Which finding indicates the need for follow-up care?

30-degree abduction of the infant's hips

The hospital management is planning a study that compares the benefits and harms of a particular method to the benefits and harms of alternative methods when treating clients with chronic disorders. Which approach does the nurse manager follow to improve client care?

Comparative effectiveness research (CER)