Hesi exit review PN

The nurse-manager asks a newly hired LPN if the facility's rules of ethical conduct are understood. Which statement by the LPN indicates the need for FURTHER education?

"I don't discuss advance directives unless the client initiates the conversation."

The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best?

"I must respect your mother's rights until she is legally deemed incompetent."

A client diagnosed with cancer tells the nurse about wanting to stop treatment and die at home. The healthcare team suggests another round of chemotherapy. What statement by the nurse to the healthcare team best reflects client advocacy?

"The client has expressed not wanting to pursue additional treatment."

A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond?

"The goal is teaching the client how to perform self-care activities."

A nurse is assigned to care for four clients. Which client should a nurse assess first? A postoperative client who just returned from surgery and is vomiting A client with gastroenteritis and fever A client with recurrent diarrhea A client with a history of gastric bleeding

A postoperative client who just returned from surgery and is vomiting

A nurse is working within the managed care delivery model. Which is true regarding managed care?

All systems reflect the values of efficiency and effectiveness.

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation? Tell the charge nurse that the statement is hurtful. Tell the charge nurse to be more specific about what is meant. The new nurse should discuss feelings with a coworker in order to vent. Ask for a private meeting to explore the charge nurse's concerns in detail.

Ask for a private meeting to explore the charge nurse's concerns in detail.

Which trait is the most important for ensuring that a nurse-manager is effective?

Communication skills

A client with self-inflected wrist lacerations was stabilized in the emergency department and then transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. After initiating antidepressant therapy, the client is now exhibiting an increase in energy levels. What nursing intervention is most appropriate?

Continue suicide precautions.

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care?

Good Samaritan laws are designed to protect the caregiver in emergency situations.

A nurse manager is reviewing staff behaviors that are resulting in elevated operating costs on the acute inpatient unit. Which behavior(s) will the nurse manager address with the nurses on the unit as contributing to waste? Select all that apply.

Instructing unlicensed assistive personnel to strip all linens from clients' beds each morning. Storing dressing and other disposable supplies at the bedside of a client on contact precautions. Sending routine culture and sensitivity testing on client's blood from central venous devices.

The nurse has just received the shift report. Which client should the nurse assess first?

a 60-year-old client admitted with chronic obstructive pulmonary disease (COPD) whose oxygen saturation level is 84%

The nurse is assigned to care for the following clients. Which client should the nurse see first?

a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute

A client is suspected to be experiencing a myocardial infarction (MI). Which symptom reported by the client would lead the nurse to this conclusion?

chest pain

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is mostimportant for the nurse to address with the mother to promote a trusting relationship?

communication barriers between the mother and staff

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?

development of an increase in mobility

A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when

documenting medications after administration.

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

elevate the affected part

The nurse is documenting client information in the client's medical record. Which action by the nurse is appropriate when documenting information in a client's medical record?

ending each entry with a signature and title

When collecting data on a child with cellulitis, which symptoms would the nurse expect to find? pale, irritated, and cold to touch vesicular blisters at the site of the injury fever, edema, tenderness, and warmth at the site swelling and redness with well-defined borders

fever, edema, tenderness, and warmth at the site

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention?

include the client in the decision-making process

A client is admitted to the rehabilitation unit after hospitalization for a hip fracture. Which plan by the multidisciplinary team best optimizes client outcomes?

including the client in developing a care plan that works toward meeting discharge goals

The school nurse is gathering data related to the diabetic status of a 15-year-old athlete. Which physiologic change should the nurse anticipate as a diabetic teenager becomes more physically active during the day?

increased need for food

A nurse measures a client's apical pulse rate as 82 beats/min while another nurse simultaneously measures the client's radial pulse as 76 beats/min. What term will the nurse use to document this finding?

pulse deficit

The charge nurse overhears a nurse complaining that she has been assigned to a toddler diagnosed with tetralogy of Fallot for the past 3 days and the mother is very demanding. Which response by the charge nurse is best?

"It's important for the child to have someone assigned to him who's familiar with his care."

When reinforcing education with parents of an infant newly diagnosed with diabetes insipidus, which statement by the parent indicates an appropriate understanding of this condition? "When my infant stabilizes, I won't have to worry about giving hormone medication." "I don't have to measure the amount of fluid intake that I give my infant." "I realize that treatment for diabetes insipidus is lifelong." "My infant will outgrow this condition."

"I realize that treatment for diabetes insipidus is lifelong."

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate?

"I will ask the surgeon to come speak to you about the procedure."

The health care provider is in a client's room doing an assessment. The health care provider walks out of the room and says to the nurse, "I have prescribed furosemide 40 mg orally twice daily for 5 days. Enter the prescription into the computerized order entry system for me." What is the bestresponse by the nurse?

"I will find you a computer that is not being used so you can enter the order into the computerized order entry system."

The nurse offers a client items to perform oral care before breakfast. The client refuses the care, stating, "I prefer to brush my teeth after my meal." Which statement by the nurse is mostappropriate?

"I will note on your chart that you prefer oral care after meals."

A female client is scheduled to undergo abdominal surgery for possible ruptured tubal pregnancy. A nurse is witnessing the client's signature on a consent form. Which client statement would the nurse interpret as the best indicator of the client's informed consent?

"The health care provider may have to remove my fallopian tube if it has burst."

The recipient of a donated organ asks the nurse, "What did the donor die from?" Which response by the nurse is most appropriate?

"The transplant coordinator can give you information about the donor's medical history."

A graduate nurse is discussing verbal orders with the nurse preceptor. What statement by the graduate nurse requires the nurse preceptor to provide further teaching?

"When I receive verbal orders, they must be carried out immediately to ensure clients get prompt care."

An Asian-American client with hyperglycemia is admitted to the healthcare facility. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood glucose level under control. The nurse determines that saffron is not known to influence blood glucose levels. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?"

A client in the final stages of terminal cancer tells the nurse, "I wish I could just be allowed to die. I'm tired of fighting this illness. I have lived a good life. I continue my chemotherapy and radiation treatments only because my family wants me to." How should the nurse respond?

"Would you like to meet with your family and health care provider about this matter?"

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the mostappropriate response by the nurse? "You have a right to withdraw consent. Can you share more about your decision?" "You have the right to refuse treatment. I'll let the healthcare provider know." "You can always change your mind afterwards. Did you want to try to see how it feels first?" "I respect your right to make that choice. However, do you think you may just be scared?"

"You have a right to withdraw consent. Can you share more about your decision?"

A team conference has been called to discuss alternative treatment for a Jehovah's Witnesses client who has a hemoglobin level of 5.5 g/dL. Which fact regarding the religious beliefs of a Jehovah's Witness should be explained to the team during the conference?

A Jehovah's Witness is forbidden from receiving blood products.

A nurse-manager is reviewing incidents that occurred recently. For which event will the manager need to make a report to the board of nursing?

A nurse documents administering narcotics to a client while personally using the medication.

A client diagnosed with gestational hypertension must have weekly blood pressure checks and urine testing at a clinic. She does not have transportation. How can the nurse help this client be compliant with her care?

Ask the clinic case manager to speak with the client.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

The unlicensed assistive personnel (UAP) reports to the nurse that a client became short of breath while being bathed but is breathing better now. Which action should the nurse take first?

Check the client and gather subjective and objective data related to shortness of breath.

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take?

Clearing the client's airway

A client tells a nurse that her ileoconduit appliance won't adhere to her skin. The nurse inspects the site and notes that the area around the stoma is red, moist, and tender to touch. How should the nurse intervene?

Consult the wound-ostomy nurse.

The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the nextaction by the nurse?

Contact the surgeon to answer the client's question.

A licensed practical nurse (LPN) is planning client assignments in a long-term care facility. The LPN is deciding which tasks to perform and which to delegate to an unlicensed assistive personnel (UAP). Which task must the LPN perform?

Performing dressing changes

After being informed that a client is to be admitted to the hospital for stabilization of the client's diabetes, the client's child returns to the hospital 6 hours later to find that the client remains on a stretcher in the emergency department hallway. The child begins to shout "I will not allow my insurance to pay for your failure to provide care." What is the best action for the nurse to take in this situation?

Ensure the comfort and security of the client and meet privately with the family member.

The nursing student and nursing instructor are discussing the planning stage of the nursing process. When asked what actions are performed in this stage, which responses provided by the student would indicate to the instructor that the discussion was effective? Select all that apply. "In this stage, the nurse determines the client's goal achievement." "A statement about the client's health problem is written in this stage." "Establishment of short- and long-term goals is determined." "This stage projects measurable outcomes." "In this stage, the nurse gathers objective data."

Establishment of short- and long-term goals is determined." "This stage projects measurable outcomes."

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client? Impaired gas exchange Impaired skin integrity Activity intolerance Imbalanced nutrition: Less than body requirements

Impaired gas exchange

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and reports acute chest pain. What action should a nurse take first? Initiate oxygen therapy. Administer a heparin bolus and begin an infusion at 500 units/hour. Administer analgesics, as ordered. Perform nasopharyngeal suctioning.

Initiate oxygen therapy.

An adolescent client is admitted for a sickle cell crisis. Which intervention is most important for the nurse to implement? Gather information about the child's ability to cope. Monitor the child's temperature every 4 hours. Manage pain aggressively and continually. Involve the family in every step of the child's care.

Manage pain aggressively and continually.

A nurse has been voicing concerns to colleagues about unfair client assignments being assigned by the charge nurse with some nurses consistently having less complex client assignments than others. What action should the charge nurse take upon learning this information?

Meet with the nurse privately and provide an opportunity to express concerns

Which factor is most important when planning care for a client with a bleeding disorder?

Prioritization

The quality control nurse is reviewing clients' charts on the medical-surgical unit. When reviewing the nursing staff nursing notes, the quality control nurse expects to find which factors? Select all that apply. Charting errors are erased. Nursing notes follow chronological order. Nursing notes are written with a #2 pencil. Nurses leave one line blank before each new entry. Nurses end each entry with the nurse's signature and title.

Nursing notes follow chronological order. Nurses end each entry with the nurse's signature and title.

A nurse is admitting a client with tuberculosis who is coughing. To minimize the transmission of tuberculosis, which nursing measure is most appropriate? Wear a N95 disposable respirator when entering the client's room. Wear gloves and an N95 disposable respirator when entering the client's room. Restrict visitors until the client has taken antituberculin medications for 2 weeks. Place the client in a positive-pressure room with windows that are open.

Wear a N95 disposable respirator when entering the client's room.

A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor?

Remain in the operating room suite until another nurse arrives to take that assignment.

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate?

Remove the clients to separate areas and set limits

A nurse is assigned to a client who is using an insulin pump. The nurse has never cared for a client with an insulin pump and isn't sure what to do. What should the nurse do first?

Request information about nursing responsibilities in caring for a client with a pump.

An alert and oriented adult client who is a Jehovah's Witness refuses a life-saving blood transfusion. The client's partner, who is not a Jehovah's Witness, requests that the client receive the blood. Which is the most appropriate action by the nurse?

Respect the client's right to refuse the transfusion.

A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer?

Suggest a consult with a wound care specialist.

A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer? Clean the ulcer with povidone-iodine solution, and wrap it with clean gauze. Tell the patient that this is to be expected. Suggest a consult with a wound care specialist. Complete the client's vital signs, document any increase in temperature, and set up an appointment for the next week.

Suggest a consult with a wound care specialist.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

The nurse plans to obtain client information from a primary source. Which does the nurse identify as a primary information source and collects data from?

The client

A client with a history of major depression established a psychiatric advance directive that was deemed legally valid. The directive specified that the client did not want electroconvulsive therapy (ECT) at any time. The client is legally competent and has expressed a renewed interest in trying ECT. The nurse should anticipate what event?

The client may revoke or amend the terms of the advance directive.

A nurse is discussing end of life care with a client's family in a skilled nursing facility. The client's advanced directive states the client wants no life support treatments. What are important nursing considerations to determine the efficacy of the advanced directive? Select all that apply.

The client signed the form. The advanced directive has two signatures. The advanced directive has a durable power of attorney.

A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which action would the nurse incorporate to best promote compliance by this client?

The contract should be written jointly by the client and nurse.

Which scenario below complies with the HIPAA (Canadian Privacy Act and Personal Information Protection and Electronic Documents Act) regulations? Two nurses in the cafeteria are discussing a client's condition. The healthcare team is discussing a client's care during a formal care conference. A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor. A nurse talks with the spouse about a client's condition.

The healthcare team is discussing a client's care during a formal care conference.

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?

discussing the purpose of the vaccine and providing the client with written information

A licensed practical nurse (LPN) is working on a wing of a medical-surgical unit that is also staffed with a registered nurse and a certified nursing assistant (CNA). When providing care, which task would be most appropriate for the LPN to delegate to the CNA?

encouraging a client to drink fluids

The nurse is called to serve as a fact witness in the court of law. Which qualifications support the nurse fact witness role? Select all that apply.

firsthand knowledge of the situation clinical documentation of the incident

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priorityfor the client? learning to express feelings establishing new roles in the family determining new strategies for socializing decreasing preoccupation with physical health

learning to express feelings

In many institutions, which telephone or fax orders requires a signature within 24 hours by the ordering physician or nurse practitioner?

orders for antibiotics

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section?

physician

A school-age child reveals to the nurse that a parent has been abusive. What constitutes a breach of the child's right to confidentiality?

telling the child in the next room, who also suffered abuse, so the two children can talk to each other

A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?

to allow staff members to discuss concerns about working with a client with DID

Reusable blood pressure cuffs and single-use disposable blood pressure cuffs are both available for use in the emergency department. In order to conserve resources, for which client would a clean, reusable blood pressure cuff be appropriate?

an 87-year-old female client in the emergency department for chest pain

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of: beneficence. autonomy. advocacy. justice.

autonomy