Hesi management

a UAP is stuck in the palm of his hand by a need that is found in the bed of a client dx with hep b, which action should the charge nurse instruct the UAP to do first? wash hands with soap and water

wash hands with soap and water

To facilitate the success of a new fall prevention program, which action should the nurse manager implement? A. involve the staff in developing interventions for the program B. provide statistics on the number of client injuries related to falls C. Offer rewards to staff members who comply with the program D. Ask staff to report issues regarding the program of management

A. involve the staff in developing interventions for the program

Which older client should the charge nurse assign to the most experienced nurse? A. 72 yo client with type 1 DM who is newly dx and scheduled for discharge today B. 75 yo client who is being evaluated for a possible total knee replacement C. 80 yo client adm with chronic constipation and a fecal impaction D. 83 yo client in end stage liver failure who is terminally ill and has a do not resuscitate RX

A. 72 yo client with type 1 DM who is newly dx and scheduled for discharge today

In reviewing the admission records of a 16yr male client with acute glomeneuphritis, the nurse notes that the healthcare provider has given no instructions regarding measurement of intake. which intevention should the nurse implement? A. Ask the client what he knows about healthcare providers plan for how much he can have to drink B. Delegate the deck clerk to telephone the healthcare providers office for instructions C. Inform the family that an error was made but that was recognized early D. start the intake and output record and teach the client an family how to record fluids internet says A

A. Ask the client what he knows about healthcare providers plan for how much he can have to drink ----is what internet says

The nurse is assigned to care for four clients. After receiving the change of shift report, which client should the nurse assess first? A. Client with diabetes and a history of coronary artery disease who is complaining of increased sob? B. 10 yr old with sickle cell disease who had a morphine PCA pump, but is complaining of pain at 2 or 3 on a 10 point scale. C. 29 yr who has had CKD for the past year and has an AV fistula placed yesterday D. older client with COPD who is experiencing sob and

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 was transitioned from a patient controlled anlagesic (PCA) pump to a 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 bx is disturbing his roommate. The client's bp had increased from 120/72 to 150/96. Which question is best to include in the recommendation component of SBAR report to the surgeon? A. Could the client's bx be a manifestation of drug seeking

A. Could the client's bx be a manifestation of drug seeking bx's?

The nurse assigns a UAP to apply SCD's devices to a client, which instruction should the nurse include when assigning this task to the UAP? A. Report any change in color in the clients feet or legs B. check the clients pedal pulses before applying C. elevate the clients let on a pillow if the client reports discomfort D. the compression should start at the clients toes an move upward

A. Report any change in color in the clients feet or legs

The nurse observes a PN placing a client on the right side with the left leg bent in preparation for lumbar puncture. Which action should _____ A. demonstrate to the PN ho w to position the client more effectively for the procedure B. arrange for a UAP to assist the PN during the procedure C. Assume that the PN has positioned the client safely and correctly

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

The nurse is caring for a group of clients with the help of a UAP . several specimens can the UAP take care of? A. fecal drainage sample B. drainage from pressure ulcer C. Urine from indwelling catheter D. incisional wound drainage E. Sample of chest tube drainage

A. fecal drainage sample C. Urine from indwelling catheter

An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. instructions from healthcare provider has been received to transfer the client to a palliative care room. which action is most important for the nurse to take? A. give a detailed report to accepting nurse B. give client written information about end of life C. take the family to the clients new room D. ensure transfer of the clients electronic chart code

A. give a detailed report to accepting nurse ?

The nurse is caring for a client with syphilis (STI) the client reports having sex with someone who had many partners. which response should the nurse provide? A. inform that follow up may end after tx is finished B. emphasize that using safe sex practices removes the risk of STIs C. clarify that all STIs are transmitted through sexual intercourse D. remind non-judgmental and assure the client of confidentiality

A. inform that follow up may end after tx is finished ?

Nurse is caring for an older adult who was admitted with UTI and is now exhibiting signs of Severe Inflammatory Response Syndrome (SIRS) which collaborative care goals should the nurse include in the plan of care? A. negative urine culture B. incision free of exudate C. decrease blood pressure D. Body temp within normal limits E. reduce white blood cell count

A. negative urine culture D. Body temp within normal limits E. reduce white blood cell count maybe C? (. decrease blood pressure )

in planning care on the nursing unit, which task is best to assign to the RN rather than a PN? A. teach a client with diabetes to inject insulin B. remove the staples and apply sterile strips C. initiate a 24 hr urine collection D. irrigate an infected pressure ulcer

A. teach a client with diabetes to inject insulin

In planning care on the nursing unit, which task is best to assign t the RN rather than the PN? A. teach client with diabetes to inject insulin B. remove staples and apply sterile strips C. initiate 24 hr urine collection D. irrigate an infected pressure ulcer

A. teach client with diabetes to inject insulin

the charge nurse assigns an experienced PN to care for a client who needs complex dressing change. the female PN who seems anxious with dressings feel competent to perform the procedure. which is the best way for the charge nurse to handle this situation? A. tell the PN that assistance is available if needed but that she will be responsible for the clients care B. avoid conflict with the PN and reassign the client to an RN C. reassure the PN that she is competent to perform the dressing change D. remind the PN that performing sterile dressing changes is within the scope of practice for practical nurses

A. tell the PN that assistance is available if needed but that she will be responsible for the clients care

The RN is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the ED nurse ___immediately. A practical nurse PN and UAP are available to assist the RN. How should the RN assign both? Assign the PN to assist with thoracentesis while the nurse obtains report and the UAP prepares the room for the new patient

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

Which staff assignment made by the primary nurse requires the MOST immediate follow up action by the charge nurse on a medical unit? A. PN is assigned to transport post op client to the rehab unit B. UAP is assigned to check a client for fecal impaction C. PN is assigned to monitor the blood pressure of a client with hypertension D. graduate nurse is assigned to obtain a unit of packed red blood calls from the blood bank

B ?

after reviewing the morning laboratory findings for 4 clients which client should the nurse follow up first? A. serum glucose level for a client receiving corticosteroids increases to 150 mg B. BNP assay for a client with SOB after MI increases to 1000 pg/ml C. INR for a client who is receiving warfarin therapy increases to 2.5 D. K for a client with renal dialysis increases to 5 mEq

B. BNP assay for a client with SOB after MI increases to 1000 pg/ml

The nurse is observing the staff provide care to a client with AIDS who was admitted yesterday Pneumonia. Which staff scenario requires intervention by the nurse? A. Housekeeper using bleach solution to remove spilled blood B. UAP wearing a mask to take clients bp C. PN performing hand washing when leaving the room D. Lab technician wearing gloves while performing venipuncture

B. UAP wearing a mask to take clients bp

the nurse is assigned 4 clients on the medical unit, based on the notes taken during shift report which client situation warrants the nurses immediate attention? A. a young adult with chrons dz who reports having diarrheal stools B. a 10yr who is receiving chemo and infusion pump is beeping C. older adult with Type 2 dm whose breakfast tray arrived 20 min late D. A teenager who reports continued pain 30 min after receiving oral anagelsics

B. a 10yr who is receiving chemo and infusion pump is beeping

When making assignments for the day, which information provided during the change of shift report is MOST important for the charge nurse to consider? A. A male client was concerned about how slowly his call bell was answered yesterday B. an elderly female client refuses to be cared for by a male nurse C. postoperative client is anxious to be d/c as soon as possible today D. a newly admitted clients family is unable to stay with the client

B. an elderly female client refuses to be cared for by a male nurse

A nationally known management consultant whose consulting fee is very hhgm is scheduled to speak at a day long hospital education conference, The head nurse wants the information presented at ____be disseminated among the staff. which plan will be most useful in achieving this goal? A. schedule education leave for the staff so that all ca attend the program B. ask two staff members to attend and report what they learned to the unit's staff C. encourage the ed. dept. to schedule the program a time that is convenient for all staff D. ask 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's staff

an older client who lives alone has a hx of heart failure and is admitted to the hospital after passing out while walking to the mailbox. The nurse notes multiple Br___ treated with cardiac glycoside, diuretic and restricted sodium diet. Which intervention is MOST important for the nurse to include in the clients plan of care? A. provide low sodium diet meal choices B. continuous electrocardiogram monitoring C. Daily 12 lead ECG D. Weigh client at the same time each day

B. continuous electrocardiogram monitoring

the charge nurse on a surgical unit is assessing the morning lab work on 4 clients. which clients lab finding should be reported to the healthcare provider immediately? A. client scheduled for an elective transurethral resection of prostate that has an aPTT of 80 sec B. elderly client in end stage renal disease who has a creatine level of 2.4 and BUN 84 C. client who had hip replacement two days ago, K 3.8 and Na 147 D. adolescent who has appendectomy yesterday and had WBC of 12,000

B. elderly client in end stage renal disease who has a creatine level of 2.4 and BUN 84

the nurse notes the toes of a clients caster leg are cold and blue the healthcare provider is notified by phone 3x but 4 hrs after the first notification the healthcare provider has not come to see the pt who is now complaning of extreme pain. which action is most important for the nurse to take? A. call the healthcare provider every 15 min until a response is obtained B. have the nursing supervisor report the situation immediately to the medical chief of staff C. encourage the family to take the client to the nearest hospital ED D. record the assessment findings and each time the findings were reported to the healthcare provider

B. have the nursing supervisor report the situation immediately to the medical chief of staff

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 A. is newly dx with hypothyroidism and who is to receive the first dose of levotyhorine B. is exhibiting signs of Addisons crisis after corticosteroids were d/c C. has dm and has an elevated serum glycosylated Hbg A1C D. is two days post thyroidectomy and is unable to speak clearly due to laryngeal nerve damage

B. is exhibiting signs of Addisons crisis after corticosteroids were d/c ?

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? A. assess the clients prothrombin time (PT) INR B. obtain a RX for a PRN analgesic C. Administer RX daily aspirin now D. wait until 0830 and administer the aspirin

B. obtain a RX for a PRN analgesic ----- might be c

a 5 yr boy w with mumps is being transferred to the pedi unit, which nursing is most important for the nurse to implement? A. instruct the colds parents about the need for transmission precautions B. place an isolation cart outside of the room to initiate droplet precautions C. schedule bedside play time with occupational therapist D. assign the child to a room close to the nurses station

B. place an isolation cart outside of the room to initiate droplet precautions (??)

in planning care for a group of clients. which task should the nurse delegate to the UAP? A. remove staples from a clients week old open to air incision B. reinforce teaching provided by nurse about using call bell C. demonstrate proper technique for using a walker to ambulate D. observe a clients telemetry monitor for changes in heart rhythm

B. reinforce teaching provided by nurse about using call bell

the nurse calls a surgeon about a male client who is having and pain after a bowel resection. He hydromorphone 2 hours ago and is now requesting additional pain medication. His vital include temp: 97.8* HR 112/bpm RR 24 bp 98/62 which is lower from previous reading one hour ago. The client has hx of chronic a fib and ciopidobgret, which continued unit one day prior to surgery, The nurse recommends that the surgeon see the client immediately to evaluate the situation . What information makes this report complete? A. nasogastric suction is draining bile colored secretions B. the and is rigid, tender to touch, distended C. lungs are clear bilaterally and oxygen sat is 97% D. clients hx includes cardio version and ablation therapy

B. the and is rigid, tender to touch, distended

when the nurse manager to calculating the number of full time equivalents (fte's) that are needed to staff a unit of an acute care hospital, which factor is Most important. in determining calculation? A. average edu. of the nurses who staff the unit B. the clients acuity level C. Number of available nurses D. the degree of family involvement of clients care

B. the clients acuity level

One hour after the nurse administers an analgesic. the UAP reports to the nurse that the client refuses to turn in bed because of cont. pain. What action should the nurse take? A. assign the UAP to monitor the clients pain until relief is obtained B. Administer the additional prescribed PRN dose of an analgesic C. Asses the clients current pain level and response to the analgesic D. advise the UAP about the need for the client to turn frequently

C. Asses the clients current pain level and response to the analgesic

An older client with a history of hypertension is transferred from a long term care facility to the hospital intensive care unit because of an exacerbation of heart failure. She has signed and witnessed 'do not resuscitate' form on her record. Which action should the nurse take? A. Transfer client to a 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. As the unit supervis

C. Confirm current resuscitation wishes with client and family

the nurse watches a UAP bring soap. washcloths and towels and a basin into the room of a Ma______________implement? A. Remind the UAP to provide warmth and privacy wen washing and drying the area around the client.... B. Advise the UAP tat the clients dressing will need to be removed before cleaning around his catheter C. Tell the UAP that the nurse will perform the clients catheter care after the UAP assists with his personal____ D. Encourage the UAP to offer the client the opportunity to perform his own catheter care independently

C. Tell the UAP that the nurse will perform the clients catheter care after the UAP assists with his personal____

the nurse is workin on a post surgical ICU receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? A. an older adult who had a masectomy 2 days ago and has serosanguinous fluid in the JP drain B. a teenager who had a gunshot would repair yesterday and has quarter sized drainage on the dressing C. a young adult who had an abd-perineal resection 3 days ago and is currently c/o chlls D. adult who has a collapsed lung r/t fall from ladder 8 hrs ago and now has 100ml chest tube drainage

C. a young adult who had an abd-perineal resection 3 days ago and is currently c/o chlls

the nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. the client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse manager? A. contact the healthcare provider to ensure that a RX for restraints is written B. determine if the client has a PRN RX for an anti anxiety agent C. advise the staff nurse to remove the restraints from the clients wrists D. close the door to the room to avoid disturbing other clients in nearby rooms

C. advise the staff nurse to remove the restraints from the clients wrists

after receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse PN? A. initiate teaching for client care after d/c B. validate RX flow rates C. begin initial sterile wound care for surgical clients D. evaluate and update plans of care for clients

C. begin initial sterile wound care for surgical clients

a client with severe lateral crush injuries of lower extremities is informed by the healthcare provider that amputation is the only option for the client to live, the client measures are taken. the healthcare provider refuses to write DNR instructions , which action should the nurse take? A. remind the client that new tx are being developed daily B. facilitate a palliative care meeting with the client and healthcare provider C. initiate a review of the situation by the hospitals ethics committee D. provide the healthcare provider with a copy of the clients bill of rights

C. initiate a review of the situation by the hospitals ethics committee

The charge nurse observes a newly employed nurse begin to administer a liquid medication via a clients gastrostomy feeding tube system as seen in the picture. Which actions should the nurse take? A. advise the nurse in lowering the solution to eye level B. confirm that the nurse checked solution compatibility C. instruct the nurse to flush the bad with sterile saline D. direct the nurse to stop the medication administration (ANSWER MIGHT BE D)

C. instruct the nurse to flush the bad with sterile saline (ANSWER MIGHT BE D)

an experienced PN and a UAP are working together to assists neurological compromised clients at mealtime . which task is best for the PN to perform A. feed quadriplegic client who has difficulty chewing and swallowing B. assist a client with a ataxic gait transfer to a w/c before the meal C.. measure the allowed fluid amts. for a client on strict fluid restriction D. explain the food choices on the meal tray to a confused client

C. measure the allowed fluid amts. for a client on strict fluid restriction

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 pts, what action should nurse take? A. ask the employee to attend self awareness conference to assist in recognizing prejudices B. report the observations of this employee to the nursing and respiratory therapist supervisors C. provide the employee with feedback abut the observed bx D. avoid assigning clients who are HIV + or have AIDS to this employee

C. provide the employee with feedback abut the observed bx

the charge nurse observes that a client with nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after UAP left the room, what action for the charge nurse to take? A. discuss the incident with 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 the healthcare provider

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

contact precautions are being implemented for a client with cellulitis of right foot. the nurse observes an UAP eating candy given to her by the clients family in this clients room. what action should the nurse take? A. add an update on isolation protocols t the staff meeting agenda B. send a saliva specimen from the UAP to the lab for culture C. report the possibility of cross-contamination to infection control D. tell the UAP not the ingest anything while in a contact isolation room

C. report the possibility of cross-contamination to infection control

The nurse manager is preparing the curricula for a class for charge nurses. A staffing formula based on which data ensures quality client care and is most cost effective? A. client geographic location and age B. weekend and weekday staff availability C. skills of staff and client acuity D. # of staff and # of clients

C. skills of staff and client acuity

because of budget cutbacks a policy was est, which mandates that when the census is low, nurse will be sent home, For the third time in two weeks, a nurse wh has been employed at the hospital for 3 months is being sent home immediately after arriving to work. The nurse obviously upset and begins to cry when told to go home. which action should the charge nurse take? A. reassure the nurse that this hospital policy and has nothing to do with the nurses capabilities B. write a letter to administration describing the unfair situation and encourage all employees to sign it C. take the nurse to a private place and listen to the nurses description in of concerns D. call the supervisor and report that the staffing has unfairly caused the new employee financial stress

C. take the nurse to a private place and listen to the nurses description in of concerns

The nurse hears a newly UAP who us working with long term care facility calling the adults residents "honey" and "deary" what is the best action to take? A. role model the correct approach for addressing the residents B. call a staff meeting to encourage more professional bx C. ask the long term facility supervisor to rebuke the USP D. meet the UAP to discuss respectful client care strategies

D. meet the UAP to discuss respectful client care strategies

The charge nurse In an emergency center is panning client care assignments for the staff, which action may be safely delegated to the practical nurse PN? A. Evaluate client teaching through return demonstration? B. Est. blood pressure parameters for client monitoring C. Provide client with resources and discharge teaching D Remove a peripheral intravenus catheter

D Remove a peripheral intravenus catheter

The RN is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the ED nurse____immediately . A proactive. nurse and UAP are available to assist the RN. How should the RN assign the necessary ___ A. Assig PN to go to ED to obtain report and transport the client while the UAP prepares the room an the RN assists B. Assign UAP to prepare the room while the PN obtains report on the new admission and the RN assists the thoracentesis C. Assign the UAP to assist with thoracentsis while the PN goes to the ED to transport the client to the unit and the RN____ D. Assign the PN to assist with the thoracentesis while the nurse obtains report and the UAP prepares the room for new admission

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

4 clients are schemed to receive IV infusions, but there are only 3 IV pumps available. which RX infusion can most safely be administered w/o IV infusion rate? A. regular insulin in normal saline RX for ketoacidosis B. heparin in normal saline prescribed for DVT C. MAg in normal saline RX for hypomagnesemia D. Celtraxone in 5% dextrose in water prescribed for pneumonia

D. Celtraxone in 5% dextrose in water prescribed for pneumonia

The nurse manager conducts regular audits of patient care medication records, and notices that the amount of narcotic pain medications ___action should the nurse manager take first? A. Hold a mandatory staff meeting to discuss the findings of documentation audits from every shift B. Discuss with healthcare provider a plan to change client analgesia C. Question clients about effectiveness of pain medication D. Conduct a closer examination of staff nurse's distribution of pain medication from evening shift

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

the nursing supervisor sends a UAP to a medical unit to replace an absent UAP. when delegating the task of obtaining clients what 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 electronic client record C. ask the UAP to describe the normal blood glucose levels for fingerstick analysis D. Observe the UAP obtain a BG using a glucometer

D. Observe the UAP obtain a BG using a glucometer

A healthcare provider 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 forms such as lab and radiology requisitions B.. Clarify the Rx with the unit clerk to ensure accurate transcription 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 nurse RN, practical nurse PN and UPN are working as a team to provide care for an acutely ill client requiring immediate bedside insertion of the chest tube. Which assignment is the best use of each person's skills? A. The RN inserts the chest tube immediately after the PN cleanses the skin at the insertion site B. The UAP listens to breath sounds while the RN witnesses the informed consent C. The PN instructs the family about the need for the chest tube insertion while the RN obtains the vi

D. The UAP obtains an oxygen sat level while the RN reports findings' to the healthcare provider

A UAP is stuck in the palm of the hand that is found in bed linen of a client dx with HEP B. Which action should the charge nurse instruct the UAP to do first? A. complete and file an incident report B. Hve blood tests drawn per policy C. Report to the employee health nurse D. Wash hands with soap and water

D. Wash hands with soap and water

Is it most important to assign which client to a RN rather than PN? A. 1 hr after receiving hydromorphone RX for q4h prn use, a client reports severe pain B. 2 hrs after receiving morphine for acute pain a clients VS : BP 112/60, pulse 88, RR 14 C. Fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced D. after ambulating a post op client grimaces and reports incisional pain at a 9' on a ten point scale

D. after ambulating a post op client grimaces and reports incisional pain at a 9' on a ten point scale

the home health aide is caring for a homebound hospice client calls to inform the nurse that the client has reported feeling_____ A. listen for presence of bowel sounds B. administer a prescribed dose of laxative C. teach client about foods high in fiber D. assist the client to drink warm prune juice

D. assist the client to drink warm prune juice

the nurse is reviewing the laboratory results for 4 clients on the medical unit, in addition to using standard precautions, the client with which finding should also be placed on airborne precautions? A. MRSA B. Urine culture reveals colonies of Ecoli C. jaundiced with positive antibody titers for HEP A D. culture of a elf reveals pseudomonas aeruginosa

D. culture of a elf reveals pseudomonas aeruginosa

The nurse is inserting the indwelling urinary catheter for a client experiencing retention when a code blue is called for another client on the unit who became unresponsive ....which one does she attend to? A. call for an assistant B. respond to the code C. close the room door D. finish the procedure

D. finish the procedure

a nationally known management consultant fee is very high is scheduled to speak at a day long hospital conference , the head nurse wants the info presented at the edu program to be disseminated among the staff. which plan will be the most useful in achieving this goal? ask two staff members to attend and report what they earned to the units staff

ask two staff members to attend and report what they earned to the units staff