HESI RN LEADERSHIP EXAM

HESI RN LEADERSHIP 1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provid ...

HESI RN LEADERSHIP 1. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse? a. Tell the client that a catheter will be inserted. b. Document the client’s refusal in the chart. c. Assess the client for urinary retention. d. Obtain a provider’s prescription for a blood alcohol level. 2. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Pick up the meal trays after lunch. b. Administer a nasogastric tube feeding. c. Plan break times for assistive personnel. d. Determine adequacy of ventilator settings. 3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA) a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field b. Opens the sterile pack by first unfolding the top flap away from her body c. Prepares a container of sterile solution on the field after putting on sterile gloves d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field e. Holds the sterile solution bottle with the label facing up 4. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV pump is not working properly. Which of the following actions should the nurse take first? a. Auscultate the client’s lungs. b. Notify the provider. c. Place a faulty equipment tag on the pump. d. Complete an incident report. 5. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Reinforcing teaching with a client who is learning to self-administer insulin b. Ambulating a client who is scheduled for discharge later in the day c. Administering morphine IV bolus to a client who is hr postoperative d. Admitting a new client who has chronic back pain to the unit 6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique? a. The nurse applies goggles. b. The nurse turns her back to the sterile field. c. The nurse holds her hands above her waist. d. The nurse puts on a face mask. 7. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task? a. Review vital sign trends at the end of the shift. b. Recheck vital signs that are outside the expected reference range. c. Ask the AP to write a summary of the delegated tasks during the shift. d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift. 8. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? a. Obtaining a stool sample from a client who has renal failure b. Monitoring a client who has a fluid restriction c. Assessing a client who just returned from hemodialysis d. Reviewing dietary instructions for a client who has kidney stones 9. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first? a. A client who has a neck injury and is unable to breathe spontaneously b. A client who has two open chest wounds with a left tracheal deviation c. A client who has major burns over 75% of her body surface area d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3) 10. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective? a. “A family member can interpret to obtain informed consent from a client who is deaf.” b. “Consent can be given by a durable power of attorney.” c. “Guardian consent is required for an emancipated minor.” d. “The nurse can answer any questions the client has about the procedure.” 11. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? a. A middle adult client who leaves the facility against medical advice b. An older adult client who has advanced directives on file c. A young adult client who is participating in a medical research study d. An adolescent client whose parents refuse a blood transfusion for religious reasons 12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth? a. Assessing client needs b. Developing client treatment protocols c. Providing medication reconciliation d. Establishing communication between providers (Community Health pg. 75) 13. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The client expresses concern about the cost of blood-glucose monitoring supplies. Which of the following actions should the nurse take? a. Refer the client to the social services department. b. Provide the client with a week’s worth of supplies from the hospital (still needs help paying after) c. Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often) d. Recommend the client reuse the testing lancets (breaks the safety & infection protocol) 14. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? a. A nurse on the previous shift wrote an incident report about a medication error. b. Two staff members have called to say they will be absent. c. Transport assistance is unavailable to take a client to occupational therapy. d. The emergency department nurse is waiting to give report on a new admission. 15. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management? a. Complete required tasks. b. Review the client’s new laboratory values. c. Determine client care goals (set/plan goals) d. Document assessment data. 16. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements by a staff nurse indicates understanding? a. “Clients who participate in research studies forfeit their HIPAA right to privacy.” b. “HIPAA allows facility-specific coding of client health care information to ensure privacy.” c. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.” d. “HIPAA allows clients to request a review of their own medical records.” 17. A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client’s partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? a. Whether the client understands the risk of refusing the procedure b. Whether the facility ethics committee reached a consensus on the case c. Whether the partner is the client’s durable power of attorney for health care d. Whether the client’s refusal is based on religious belie