HESI-RN-LEADERSHIP-AND-MANAGEMENT-EXAM-20-Versions-1200-Verified-Q-A-Latest-2022/2023,100% CORRECT

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HESI-RN-LEADERSHIP-AND-MANAGEMENT-EXAM-20-Versions-1200-Verified-Q-A-Latest-2022/2023 5. Client satisfactory surveys from a med-surg unit indicate the pain is not being adequately reliev... ed during the first 12 hr post-opt. The unit manager decides to identify post-opt pain as a quality indicator. Which of the following data sources will be helpful in determine the reason why clients are not receiving adequate pain management after surgery? A. Prospective chart audit B. Retrospective chart audit C. Postoperative care policy D. Pain assessment policy 6. A nurse precepting a newly licenced nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask? A. “Did you secure the restraints to the side rails of the bed?” B. “Are you able to insert two fingers between the restraint and the client‟s skin?” C. “Did you tie the restraints using double knot?” D. “Are you removing the client‟s restraints every 4 hr?” 7. A nurse is caring for an older adult client who has stage III pressure ulcer. The nurse request a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? A. Arrange the consultation for time when the nurse is caring for the client is able to be present for consultation B. Provide the consultant with subjective opinions and beliefs about the client‟s wound care C. Request the consultation after several wound care treatment tried D. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatment 8. A client is admitted wit TB and placed in a negative pressure room. Which of the following actions is appropriate? A. Notify the local health department of the admission B. Place a sign on the client‟s door with the diagnosis C. Ensure that admitting staff undergo PPD skin tests D. Determine who had contact with the client in the last 48 hr 9. A nurse is caring for a client who is unconscious and whose partner is health care proxy. The partner has spoken with the provider and wishes to discontinue the client‟s feeding tube. The provider states the nurse, “I will not discontinue the client‟s treatment. His partner has no right to make decisions regarding the client‟s care. “Which of the following responses by the nurse is appropriate? A. You should consider speaking with the facility‟s ethics committee before making your decision B. You have the right to make decision, even if the partner is the client‟s health care proxy C. The client has designated his partner as health care proxy in his advance directives D. We‟ll need to have the nursing supervisor review the client‟s advance directives 10. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following info is most important for the nurse to report at shift change? A. Gasglow Coma scale score B. Most recent blood glucose reading C. Lab test scheduled for next shift D. Reddened area on the coccyx 11. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first? A. A client who has a hip fracture and is in Buck‟s traction B. A client who has aspiration pneumonia and a respiratory rate of 28/min C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot D. A client who has a C diff infection and needs a stool specimen collected 12. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take? A. Notify the nursing supervisor about the issues B. Contact the client‟s physical therapist C. Apply a warm compress to the hip D. Reposition the client for comfort 13. The mother of a client with breast cancer states, it‟s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments. Which of the following actions is appropriate client advocacy? A. The nurse investigates potential resources to help the client purchase wig B. The nurse explains to the mother that most clients with cancer lose their hair C. The nurse informs the next shift nurse regarding the mother‟s concerns. D. The nurse suggests counseling for the client‟s body image issues 14. Which of the following items must be discarded in a biohazard waste receptacle? A. A urinary catheter drainage bag from a client who is post-opt B. A bed sheet from a client with bacterial pneumonia C. A perineal pad from a client who is 24-hr post-vaginal delivery D. An empty IV bag removed from a client who has HIV 15. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don‟t get better, I‟m going to quit. “Which of the following responses appropriate? A. “So you are upset about all the changes on the Unit” B. “I think you have a right to be upset, I am tired of the changes too” C. “Just stick with it a little longer. Things will get better soon D. “ You should file complaints with hospital administrator 16. According to the HIPAA regulations, which of the following is a violation of client confidentiality? A. Telephone the pharmacy with a prescription for the spouse to pick up B. Providing a copy of the record to the transporting paramedic C. Reporting a client‟s disposition to the referring provider D. Informing housekeeping staff that the client is in dialysis unit 17. A Nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintaining sterile technique? (Select all that apply.) A. Open the sterile pack by first unfolding the flap farthest from her body B. Rests the cap of a solution container upside down on the sterile field C. Removes the outside packaging of a sterile instrument before dropping into the sterile field D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile field 18. A nurse is providing care for 4 post-opt clients. The nurse should first assess the client A. Whose pulse has been steadily increasing during the past shift B. Who is reporting a pain level of 8 on a scale of 0 to 10. C. Whose urine output averaged 32 ml/hr for the past 24 hr D. Who is reporting nausea after the prescribed antiemetic was administered 19. A nurse is preparing to transcribe a client‟s med prescription in the medical record. Which of the following should the nurse recognize as containing the essential components of a medication order? A. NPH insulin 10 Units before and at bedtime B. Haloperidol (Hadol) 1mg per mouth C. Multivit every morning by mouth D. Aspirin 650 mg by mouth every 4hr 20. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? A. Recommend that he takes time to plan at the beginning of shift B. Advise him to complete less time-consuming tasks first C. Ask other staff members to take over some of his staffs D. Offer to provide care for his clients while he takes a break 21. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting, which of the following actions should the nurse take first? A. Remove the client‟s clothing B. Irrigate the exposed area with water C. Report the incident to OSHA Don personal protective equipment. 22. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed? A. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client. B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min C. A nurse explains to a client‟s family that a DNR order includes withholding comfort measures D. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better 23. A nurse is an ambulatory care setting is orienting 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 tele health? A. Assessing client needs B. Providing med reconciliation C. Establishing communication between providers D. Developing client treatment protocols 24. Which of the following put a hospital at the highest risk of infringement of client record confidentiality? A. A nurse clusters documentation of care for multiple clients? B. A provider and nurse access client info using one access code C. Paper-based charts are stored at the nurse‟s station D. A nurse performs electronic documentation outside a client‟s room 25. Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques? A. A nurse cleans up blood spill with a 1:10 bleach solution B. A nurse uses googles to perform tracheostomy suctioning C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen D. A nurse places a mask on a client with TB before transport to the radiology department 26. Which of the following should lead a nurse to suspect abuse that must be reported? A. A school-age child has several bruises on her lower legs. B. A toddler cries whenever his parents enters the hospitals room. C. An Adolescent admitted to the emergency won‟t speak to his parents D. A preschool child who was previously toilet trained now requires diapers in the hospital 27. A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse? A. Liaison B. Pastoral care provider C. Health educator D. Personal Health counselor 28. A nurse performing triage during a mass casualty incident should recognize that which of the following clients should be transported to the hospital first? A. A client who reports substernal chest pain radiating to the neck ????? B. A client who has an open fracture of the femur C. A client who has a 4-inch laceration on the forearm D. A client who has a penetrating head injury and fixed dilated pupils 29. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? a. “Once I sign my living will, a family member must co sign it” b. “I will wait until I have a serious health problems to sign my advance directives” c. “My doctor will need to provide approval for the decisions outlines in my living will d. “My durable power of attorney for health care is part of my advance directives” 30. A nurse manager overhears a provider and a staff nurse talking about a client‟s diagnosis in the cafeteria. Which of the following actions should the nurse take first? A. Provide a staff in-service about client confidentiality B. Report the incident to the nursing supervisor C. Remind them that the client info is confidential ???????? D. Fill out an incident report regarding the situation 31. A client has a substance use disorder is admitted to the mental health Unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states: “It‟s Ok. Soon everything will be just fine.” Which of the following is the nurse‟s primary first action? A. Ask the client if he has considered hurting himself B. Provide the client with info about Alcoholics Anonymous C. Encourage the client to participate in physical activities D. Reinforce the need to follow up with the discharge referral 32. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administer the injection. This illustrate which of the following? A. False imprisonment B. Battery C. Assault D. Libel 33. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first? A. Report the situation to the director of nursing B. Have a blood alcohol level drawn from the nurse C. Document a factual description of the situation D. Remove the nurse from the unit 34. A nurse observes a paper bag at the bedside of a client. This finding suggest that the client is receiving treatment for which of the respiratory disorders A. Asthma B. Hyperventilation C. Stidor D. Atelectasis 35. A nurse is preparing the discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report? A. Lab results within the expected reference range B. List of regularly prescribed meds C. Date of last bowel movement D. Level of consciousness 36. 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. Review the client‟s new lab values B. Document assessment data C. Complete required tasks D. Determine client care goals 37. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed indicates understanding of isolation guidelines? A. I will instruct visitors to wear a mask when visiting a client who is on contact precaution B. I will place a client who has compromised immunity in a negative-pressure airflow room C. I will wear N-95respirator mask when caring for a client who is on droplet precaution D. I will have a client who is on airborne precautions wear a mask when out of her room 38. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse? A. Changing the dressing on a postoperative wound B. Referring a client to social services for assistance with transportation C. Instructing a client who is obese about a low-fat diet D. Providing the first oral feeding to a client following a stroke 39. A case manager working in a rehabilitation unit is discharging to home a client who a spinal cord injury level C-7. Which of the following is the priority action creating the discharge plan? A. Select strategies for cost-effective home care B. Identify the client‟s ability to perform activities of daily living C. Provide educational handouts related to care requirements. D. Recommend community resources available to assist with client care. 40. A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first? A. A client who has a nasogastric tube to intermittent suction and reports nausea B. A client who has an early morning blood glucose of 220 mg/dl C. A client who had a bladder scan that indicated 250 ml of urine in the bladder D. A client who is 3 days post-opt & whose dressing has serosanguinous drainage 41. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? A. Plan break times for assistive personnel. B. Pick up the meal trays after lunch. C. Administer a nasogastric tube feeding. D. Determine adequacy of ventilator settings 42. An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires A. Recording of daily intake and output B. Assistance with meals C. A complete bed bath D. Frequent dressing changes 44. A nurse is caring for 4 clients. Which of the following tasks can be delegated to an assistive personnel? A. Assessing a client who just returned from hemodialysis B. Reviewing dietary instructions for a client with kidney stones C. Obtaining a stool sample from a client with renal failure D. Monitoring a client with a fluid restriction 45. A charge nurse is making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? A. Inform the unit manager of the incident B. Remove the restraints from the client‟s wrists. C. Speak with the AP about the incident D. Review the chart for non-restraint alternatives for agitation. 46. A client is brought to the emergency department (ED) following a motor-vehicle creash. 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. Document the client‟s refusal in the chart B. Tell the client that a catheter will be inserted C. Obtain a provider‟s prescription for a blood alcohol level. D. Assess the client for urinary retention. 47. Nurses on an impatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? A. Use clean gloves rather than sterile gloves for colostomy care. B. Wait to dispose of sharps containers until they are completely full. C. Return unused supplies from the bedside to the unit‟s supply stock. D. Store opened bottles of normal saline in a refrigerator for up to 48 hr. 48. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? A. Turning the client B. Recording the client‟s vital signs C. Determining the client‟s pain level D. Checking the pulses of the client‟s right foot. 49. To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies in the nurse manager using? A. Compromising B. Collaborating C. Cooperating D. Competing 50. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a med-surg unit? A. A client who has gestational diabetes and is receiving biweekly nonstress tests B. A primigravida client who is 1 day post-opt following a cesarean section and has a PCA pump C. A multigravida client who has preemclampsia and is receiving mistoprostol (Cytotec) for induction of labor. D. A client who is at 32 weeks of gestation and has premature rupture of membranes. 51. A nurse working on a med-surg unit is managing the care of 4 clients. The nurse should schedule an interdisciplinary conference for which of the following clients? A. A client who is at risk for pressure ulcers and has an albumin of 4.2 g/dl B. A client who has type 1 DM and uses insulin pump C. A client who has orthostatic hypotension and is receiving IV fluids. D. A client who is receiving heparin and has an aPTT of 34 seconds 52. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? A. Prophylatic treatment should be initiated after a needlestick during preparation of an injection B. I should stop the bleeding as soon as possible following a needlestick injury C. An incident report should be completed if a client receives a stick from her own used needle D. The needle should be recapped to prevent injury during transport to the biohazard container. 53. A nurse on a medical surg Unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following taks should the nurse assign to the LPN A. Obtaining a urine specimen from an older adult client B. Providing postmortem care for a client who has just died C. Accompanying a client who just had a wound debridement to physical therapy D. Reinforcing dietary teaching with a client who has heart disease 54. A nurse enters the room of a client who is unconscious and finds that the client‟s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? A. Recommend the son meet with the provider to get info about his mother‟s condition B. Complete an incident report regarding the breach of the client‟s confidentiality C. Log out of the computer so that the client‟s son is unable to view his mother‟s info D. Report the possible violation of client confidentiality to the nurse manager 55. A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene? A. The oxygen machine has a grounded plug ????????? B. The family keeps a spare oxygen tank in the room C. The window of the client‟s room are open D. The client is covered with a woolen blanket Rationale: Oxygen therapy safety precaution: Avoid materials that generate static electricity, such as woolen blankets and synthetic fabrics. Advise clients and caregivers to wear cotton fabrics and use cotton blankets. 56. A nurse is teaching a client how to use a finger stick glucometer at home. Which of the following instruction should the nurse include? A. Elevate the arm for 1 min before taking the blood sample B. Cap the lancet prior to putting it in in the trash C. Obtain the blood sample from the finger pads. D. Warm the hands prior to piercing the skin 57. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? A. Contact the client‟s next of kin to obtain consent for treatment. B. Proceed with treatment without obtaining written consent C. Have the client sign a consent for treatment. D. Notify risk management before initiating treatment. 58. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? A. The client should avoid using microwave oven to heat food ???????? B. Regular programming evaluations can be conducted by telephones C. The client should avoid using remote control devices to prevent dysrhythmias D. Suctioning could cause the unit to have an electrical shock. 59. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that 6 of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? A. Reinforce the potential consequences of not having this info on record to the nursing staff. B. Ask the nurses who are caring for clients without this info in the medical record to obtain it. C. Meet with nursing staff to review the policy regarding advance directives. D. Remind nurses to obtain this info during the admission process. 60. A client is admitted with COPD. Which of the following findings should the nurse report to the provider? A. Oxygen saturation 89% on room air. B. WBC‟s count 9,000/mm C. Report of dyspnea on exertion D. Bilateral crackles on auscultation of lungs. 61. A charge nurse notices 2 staff nurses are not taking meal breaks during 8-hr shifts. Which of the following actions should the nurse take first? A. Provide coverage for the nurse‟s breaks. B. Determine the reasons the nurses are not taking scheduled breaks. C. Discuss tie management strategies with the nurses. D. Review facility policies for taking scheduled breaks. 62. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client‟s care? (Select all that apply.) A. Occupational therapist B. Nutritional therapist C. Physical therapist D. Mental Health counselor E. Case manager 63. A nurse manger 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. Guardian consent is required for an emancipated minor B. Consent can be given by a durable power of attorney. C. A family member can answer any questions the client has about the procedure. D. The nurse can answer any questions the client has about the procedure 64. A nurse on a medical-surg unit is caring for 4 clients. This nurse should recognize that which of the following clients is the highest priority? A. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy. B. A client who has peripheral vascular disease and has absent pedal pulse in right foot. C. A client who is post-opt following a laminectomy 12 hr ago and is unable to void. D. A client who has methicillin-resistant Staphylococcus Aureus (MRSA) and has an axillary temp of 38 degree C ( 101 F) 65. A client scheduled for a tubal ligation procedure starts to cry as she wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? A. It‟s not too late to cancel the surgery if you want to B. This won‟t take long and it will be over before you know it. C. Why did you make the decision to have this procedure D. You shouldn‟t be worried because the procedure is very safe 66. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? A. A client who has a raised red skin rash on his arms, neck, and face B. A client who reports right-sided flank pain and is diaphoretic C. A client who reports shortness of breath and left neck and shoulder pain D. A client who has active bleeding from a puncture wound of the left groin 67. A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan tot ake first of the quality improvement process? A. Review current literature regarding client falls. B. Implement a fall prevention plan C. Notify staff of the increased fall rates D. Identify clients who are at risk for falls 68. A nurse is evaluating a newly licensed nurse who is administering a vitamin K (Aquamephytoin) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.) A. Selects the dorsogluteal site to administer the injection B. Cleans the injection site with alcohol C. Applies gentle pressure at the site after injection D. Aspirate the syringe for blood return after needle insertion E. Inserts the needle at a 45 degree angle. HESI LEADERSHIP 2 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 belief 18. A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse assign to a licensed practical nurse? a. Conduct the newborn hearing screening. (RN assessment) b. Administer a hepatitis B vaccine. c. Perform a New Ballard screening. (RN assessment) d. Obtain vital signs. (CNA) 19. During a staff meeting a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? a. Train LPNs to reinforce teaching with clients using a standardized teaching plan. b. Determine factors that interfere with the documentation of client education. c. Include documentation of client education as part of unit nurses‟ annual performance evaluation. d. Offer incentives for the staff once the unit‟s results are back in adherence with the benchmark. 20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? a. Utility b. Autonomy c. Nonmaleficence d. Veracity 21. A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr (improvement) b. A client who has diabetes mellitus and reports paresthesia in his fingers and toes (ABC--circulation) c. A client who has a nasogastric tube and has crackles in the lungs (ABC-- airway) d. A client who has a new diagnosis of Graves‟ disease and a TSH level of 0.2 microunits/mL 22. A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first? a. A client who is in Buck‟s traction for a left hip fracture (can‟t necessarily move too much) b. A client who is 1 day postoperative following thoracic surgery and has a chest tube (possible physical instability) c. A client who is confused and restrained for safety (still needs continual nursing care/assessment) d. A client who is receiving IV chemotherapy and is ambulatory 23. A nurse enters the room of a client who is unconscious and finds that the client‟s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? a. Recommend the son meet with the provider to get information about his mother‟s condition. b. Report the possible violation of client confidentiality to the nurse manager. c. Complete an incident report regarding the breach of the client‟s confidentiality. d. Log out the computer so that the client‟s son is unable to view his mother‟s information. 24. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? a. Explain the risks of the procedure to the client. b. Convey the client‟s request to the nurse who witnessed the consent. c. Check to see if the medial record indicates the provider explained the procedure to the client. d. Notify the provider about the client‟s concerns. 25. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? a. A client who reports a headache with sensitivity to light b. A client who reports an urge to void but has not urinated during the prior shift c. A client who reports indigestion and pain in her jaw d. A client who reports feeling lightheaded when he stands up from a lying position 26. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? a. Discuss time management strategies with the nurses. b. Determine the reasons the nurses are not taking scheduled breaks. Assess first c. Provide coverage for the nurses‟ breaks. d. Review facility policies for taking scheduled breaks. 27. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care? a. Has the AP checked the client‟s pain level prior to turning her? (RN only - do not delegate what you can EAT = evaluate, assess, teach) b. Is the client‟s family present so the AP can show them how to turn the client? (this is not necessary) c. Has data been collected about specific client needs related to turning? (Assessment of holistic care r/t pt needs and what the experienced AP can do) d. Does the AP have the time to change the client‟s central IV line dressing after turning her? (AP cannot change dressings) 28. A nurse is preparing to transfer a client from the emergency department to a medical- surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report? a. A prescribed consultation -under situation b. The client‟s vital signs c. The client‟s name -under situation d. The client‟s code status -under situation 29. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupation therapist is necessary? a. “I need some help planning my meals to maintain my weight.” b. “I am tired of having pain in my joints all the time.” c. “I‟m having difficulty climbing the stairs at my house.” d. “I will need assistance with bathing.” 30. A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse? a. Ask the adult neighbor to sign the consent form. b. Obtain consent from the hospital administrator. c. Witness the client signing the consent form. d. Attempt to notify the client‟s guardian to obtain consent. 31. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority? a. A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds b. A client who has COPD and has an oxygen saturation of 90% c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication d. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids 32. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? a. Assign clients who are not prescribed narcotics to the staff nurse. b. Collect data about the staff nurse to support further action. c. Report the staff nurse to the facility ethics committee. d. Counsel the staff nurse about substance use. 33. A nurse is assessing a client‟s comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure? a. “I will be given contrast dye during this test.” b. “I might have to wear a nose clip during this test.” c. “I might have a tube inserted into my airway during the test.‟ d. “I will run on a treadmill during this test.” 34. A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? a. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood b. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 c. An older adult client who has dyspnea and a respiratory rate of 26/min d. An adult client who has large ecchymosis on both legs 35. A home health nurse finds piles of newspapers in the hallway of a client‟s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? a. Collaborating b. Smoothing c. Accommodating d. Compromising 36. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Advising a client on self-administration of acetaminophen b. Informing a family of a client‟s progress in physical therapy c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Performing post mortem care prior to transferring the client to the morgue 37. A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include (SATA) a. Advance directives information b. Contact information for the physical therapist c. Medication guidelines information d. Insurance information e. Information about follow-up care 38. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services. When the client‟s partner asks how this service can help, which of the following responses by the nurse is appropriate? a. “This service offers psychological interventions during and after your wife‟s illness.” b. “The clinicians help reduce the severity of your wife‟s physical problems.” c. “This service delivers meals and supplies to reduce your errands away from home.” d. “It makes it possible for you to have some time away from caring for your wife.” 39. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? a. Warm the hands prior to piercing the skin. b. Cap the lancet prior to putting it in the trash.- never recap c. Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can assist to milk the blood out . d. Obtain the blood sample from the finger pads. 40. A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate the need for referral to an occupational therapist? a. Receptive aphasia→ unable to understand language in its written or spoken form b. Facial drooping→ speech therapist c. Memory loss d. Unilateral neglect –is one of the disabling features of stroke, and is defined as a failure to attend to the side opposite a brain lesion. 41. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? a. A network for communication between staff members and families b. A mental health specialist on the response team c. A sufficient supply of personal protective equipment d. A system for tracking client information 42. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? a. Rotavirus b. Pertussis c. Respiratory syncytial virus d. Group B streptococcal disease 43. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has Clostridium difficile. Which of the following solutions should the nurse recommend to clean the equipment? a. Chlorine bleach b. Triclosan c. Chlorhexidine d. Isopropyl alcohol 44. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? a. Treat and discharge the client. b. Ask the client‟s son to go to the waiting area. c. File an incident report. d. Ask the client about his injuries with the son present 45. A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? a. “I need to take my prescribed medication for 3 months.” b. “I should have a sputum culture done every 2 to 4 weeks.” c. “I need to have a TB skin test done once per year.” d. “I should wear a mask while around my family.” 46. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? a. Checking the pulses of the client‟s right foot b. Recording the client‟s vital signs c. Turning the client d. Determining the client‟s pain level 47. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an appropriate task for the AP? a. Inspect the skin of a newborn who is receiving phototherapy. – Assess b. Answer the parents‟ questions about newborn circumcision. - Teaching c. Show a new mother how to change the newborn‟s diaper. - Teaching d. Obtain the weight of a newborn that is receiving formula 48. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “A provider can write a prescription for restraints „as needed‟.” b. “I need to tie the restraint to the part of the bed frame that moves.” c. “I should tie the restraints using a square knot.” d. “I will remove a client‟s restraints every 4 hours.” 49. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? a. Mumps b. Rubeola c. Varicella d. Rotavirus 50. A nurse is caring for a client who has cancer. The client and her partner are asking the nurse about hospice are. Which of the following statements by the nurse is appropriate? a. “Hospice care will prolong the life expectancy of clients who are terminally ill.” b. “Hospice care is a multidisciplinary program for clients who are terminally ill.” c. “Hospice care is helpful for clients at various stages of chronic illness.” d. “Hospital access is no longer available for clients who are in hospice care.” 51. A nurse is planning care for a client who has Addison‟s disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Decide how often to measure vital signs. b. Explain to the client about a 24-hr urine specimen collection. c. Determine the client‟s muscle strength prior to ambulation. d. Remind the client to change positions slowly. 52. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? a. Notify the risk management department of the situation. (4) b. Review with the nurse the principles of medication administration. (2) c. Ask the nurse to describe her medication administration procedure. (1) d. Identify education opportunities for the nurse regarding safe medication administration. (3) 53. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? P. 42 ch 3 a. Libel : talking bad about someone via writing it in notes b. Battery : intentional/wrongful physical contact c. Slander : Defamation with the spoken word d. Negligence 54. A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client‟s ring? a. Place the client‟s ring in the facility safe. b. Tape the ring securely to the client‟s finger. c. Place the ring in the bad with the client‟s clothing. d. Agree to keep the ring for the client until after surgery. 55. A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first? a. Assist a client who requests help breastfeeding her 4-hr-old newborn. b. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum. c. Check uterine tone for a client who received methylergonovine- if the uterine tone is not d. Instruct a client who has an episiotomy about a sitz bath. 56. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? a. Withhold the benzodiazepine but continue the opioid. b. Contact the provider about replacing the opioid with an NSAID. c. Administer the benzodiazepine but withhold the opioid. d. Continue the medication dosages that relieve the client‟s pain. 57. A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Administers the solution at room temperature b. Points tubing in the direction of the umbilicus during insertion c. Position the client on her left side with knees flexed d. Inserts the tubing 8 cm (3.1 in) into the rectum 58. A nurse is providing information to a client about advance directives. The nurse should explain that advance directives include which of the following? P . 38 ch 3 a. Instructions regarding treatments the client desires or does not desire – (livings wills and durable power of attorney make up AD). b. Information regarding the disposition of the client‟s body upon death c. Information regarding organ donation d. A form with directions for contacting next of kin 59. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who has peripheral vascular disease ad has an absent pedal pulse in the right foot b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy. c. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38C (101F) d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void 60. A staff development nurse is giving an in-service presentation about advocacy in nursing. Which of the following statements by a nurse indicates an understanding of the role of a client advocate? a. “In the role of client advocate, I should take responsibility for coordinating each client‟s care.” b. “As a client advocate, I will suggest the best course of action for clients who are indecisive.” c. “My role as a client advocate is to empower the clients to make informed healthcare decisions.” d. “As a client advocate, I will adhere to the provider‟s prescribed treatments.” 61. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first? a. Refer the AP to the facility procedure manual. b. Instruct the AP to request assistance when unsure about a task. c. Help the AP assist the client with the transfer. d. Demonstrate the proper client transfer technique for the AP. 62. A nurse at the local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? a. Chlamydia trachomatis b. Pediculosis capitis c. Impetigo contagiosa d. Candida albicans 63. A charge nurse witnesses two nurses having a loud discussion at the nurses‟ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? a. Escort the nurses to the nurses‟ lounge to continue the discussion. b. Recommend that both nurses be terminated. c. Make arrangements to take over the client‟s care. d. Contact the house supervisor to mediate the conflict. 64. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experiences to safely care for his assigned clients. Which of the following actions should the nurse take? a. Accept the assignment with help from assistive personnel on the unit. b. Request that the charge nurse modify the assignment. c. Document the concern in the nurse‟s notes. d. Notify the risk manager. 65. A nurse is conducting an in-service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? a. Recommending a referral for a client who requires physical therapy b. Suggesting a client‟s partner attend a support group for emotional support c. Evaluating a client‟s home for safety hazards d. Completing an incident report following a medication error 66. A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse? a. Administer IV nitroglycerin to a client who is experiencing chest pain. b. Perform a urinary catheterization for a client who has experienced a cerebrovascular accident. c. Set up a trauma room for an incoming client who was in a motor-vehicle crash. d. Complete a SAD PERSONS assessment scale for a client who has attempted suicide. 67. A home health nurse is assessing the home environment during an initial visit to a client who has history of falls. Which of the following findings should the nurse identify as increasing the client‟s risk for falls? (SATA) a. A folding chair without arm rests b. A wheeled office chair at the client‟s computer desk HESI LEADERSHIP 3 4. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse? a. A client who has multiple sclerosis and ataxia b. A client who has brain tumor and is admitted for chemotherapy c. A client who has guillain-barre syndrome and a tracheostomy d. A client who sustained a concussion and is being monitored for complication 5. A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching? a. “Once I sign my living will, a family member must co sign it” b. “I will wait until I have a serious health problems to sign my advance directives” c. “My doctor will need to provide approval for the decisions outlines in my living will d. “My durable power of attorney for health care is part of my advance directives” 6. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? a. Identify the industry standards for infant safety b. Evaluate the selected infant safety system c. Choose an infant safety system d. Establish measurement criteria for infant safety systems 7. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers? a. Physical therapist b. Respiratory therapist c. Speech therapist d. Occupational therapist 8. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client's risk for falls (SATA) [repeat] • A wheeled office chair at the client's computer desk • A raised vinyl seat on the toilet in the bathroom • A throw rug covering some cracked floor • A folding chair without arm rests • A two wheeled walker used to assist the client with ambulation 9. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which of the following clients should the nurse assign to a LPN a. An older adult who has lung cancer and has periodic episodes of severe dyspnea b. A middle adult client who has a below the knee amputation and requires a dressing change c. A young adult client who is postoperative, receiving morphine via epidural, and reports pruritus d. An adolescent who requires teaching regarding insulin administration 10.While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority for the nurse to take? a. Remind nurses to obtain this information during the admission process b. Reinforce the potential consequences of not having his information on record to the nursing staff c. Meet with nursing staff to review the policy regarding advance directive d. Ask nurse who are caring for client without his information in the medical record to obtain it nurse is caring for a group of clients. Which of the following should the nurse see first? a. A client who is postoperative and has a fever. b. A client whose pressure ulcer has serosanguineous drainage on the dressing c. A client who has diabetes mellitus and is diaphoretic d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10 nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse care for first? a. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the right leg b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea c. A client who has pneumonia and requires a tracheostomy dressing change d. A client who has a new colostomy and requires discharge teaching nurse manager discovers there is a conflict between nurses working the day shift and nurses working on the night shift. Which of the following actions should the nurse manager take first? a. Acknowledge the conflict and encourage the nurses to focus on working as a team b. Gather information regarding the situation c. Encourage the nurses to resolve the conflict autonomously d. Meet with a committee from each shift to discuss issues related to the conflict nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment b. Irrigate the exposed area with water c. Remove the client‟s clothing d. Report the incident to OSHA newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? a. Complete an incident report b. Measure the client‟s vital signs c. Inform the nurse manager d. Call the provider nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? a. Decreased level of consciousness b. Generalized rash over trunk c. Increased temperature d. Report of photophobia client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a. Antibiotic therapy was initiated 2 hr after implementation of the care pathway. b. A blood culture was obtained after antibiotic therapy had been initiated c. An allergy to penicillin required an alternative antibiotic to be prescribed d. The route of antibiotic therapy on the care pathway was changed from IV to PO nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical- surgical unit? a. A client who is postterm and is receiving oxytocin for labor induction b. A client who gave birth to her first child and requires instruction on breastfeeding techniques c. A client who is 2 days post-operative following a caesarean birth and is having difficulty ambulating d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following members of the interprofessional team should the nurse consult? a. Risk management coordinator b. Clinical pharmacist c. Nursing supervisor d. Infection control nurse nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns regarding the procedure b. Provide the client with information on treatment options and outcomes c. Inform the client of the consequences of uterine prolapse and the need for intervention d. Initiate a mental health consult to determine the client‟s reasons for refusing surgery nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Delay the surgery until the nurse can obtain informed consent b. Obtain telephone consent from the facility administrator before the surgery. c. Ask the anesthesiologist to sign the consent. d. Transport the client to the operating room without verifying informed consent. nurse is planning to delegate client care assignment. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Performing postmortem care prior to transferring the client to the morgue b. Advising a client on self-administration of acetaminophen c. Teaching a client to perform a finger-stick for testing blood glucose levels d. Informing a family of a client‟s progress in physical therapy nurse is working on a quality improvement team that is assessing an increase in client fall at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? a. Notify staff of the increased fall rate b. Review current literature regarding client falls c. Implement a fall prevention plan d. Identify clients who are at risk of falls nurse is completing performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires intervention by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile. b. The AP closes the door of a client who is on airborne precautions. c. The AP Removes cut flowers from the room of a client who is in protective environment. d. The AP wears a mask when a caring for a client who has varicella. charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps for medication administration. Which of the following is priority action by the charge nurse? a. Assess the staff nurse‟s knowledge deficit. b. Pair an inexperienced nurse with an experienced nurse. c. Demonstrate use of the pump during medication administration. d. Plan an in-service education program on the unit. nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? a. Administer the initial bolus feeding to a client who has NG tube b. Check a client pain level 30min after receiving acetaminophen c. Collect urine specimen for newly admitted client d. Instruct a client to splint an abdominal incisions nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a client. Which of the following actions should the nurse take? a. Treat the client‟s injuries within 30 min b. Provide treatment for life-threatening injuries c. Provide treatment for minor injuries d. Allow the client to die without further intervention home health nurse is performing a safety assessment of a client‟s home. Which of the following findings should the nurse identify as a safety hazard? a. The client has used tracks to secure the carpet on the stairs b. The client‟s electrical cord is taped to the floor c. The client‟s bedside lamp is plugged in using an extension cord withtwo prongs d. The client stores cleaning supplies in a locked cabinet above his head charge nurse is observing a newly licensed nurse provide care for a client who has Clostridium difficile infections. Which of the following actions by the newly licensed nurse indicate an understanding of proper infection control procedures? a. Applies a mask before entering the client‟s room (It’s contact precaution) b. Removes fresh flowers from the client‟s room. c. Washes her hands with an alcohol-based hand rub after caring for the client.(no, ineffective and must wash hands with soap/water) d. Wears gown when caring for client nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client‟s need for which of the following supplies to manage tracheostomy at home? (SATA) a. Pipe cleaners b. O2 Tank c. Cotton balls d. Petroleum Jelly e. Obturator nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? a. An adult client who has alcohol intoxication- NOT FOCUSED b. An adolescent client who is legally emancipated c. An older adult client who has questions about the procedure= having questions means you dont understand, d. An adult client who has moderate Alzheimer‟s disease.- cant consent if you are not FOCUSED nurse is discussing the safekeeping of valuables with a client who is scheduled for surgery. Which of the following client statements indicates the need for further teaching? a. “I can wear my ankle bracelet since i am just having a local anesthetic: b. “I can leave my wedding ring on if it is taped in place” c. “I should remove my dentures before the procedure” d. “I should leave my valuables with a family member” nurse is caring for an older adult client who has Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? a. Request the consultation after several wound care treatments are tried b. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatments c. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation d. Provide the consultant with subjective opinions and beliefs about the client‟s wound care nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Positions the client on her left side with knees flexed b. Administers the solution at room temp c. Points tubing in the direction of the umbilicus during insertion d. Inserts the tubing 8cm (3.1 in) into the rectum nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “I should encrypt personal health information when sending emails.” b. “I can post the client‟s vital signs in the client‟s room.” c. “I can use another nurse‟s password as long as I log off after using the computer” d. “I should discard personal health information documents in the trash before leaving the unit” nurse is participating on a committee that is considering the creation of a policy that will allow the nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy? (2016 practice) a. ANA Standards of Practice b. ANA Code of Ethics c. State Nurse Practice Act d. Institute of medicine charge nurse observe a licensed practical nurse tell a client that she will return with a medication to help relieve the client‟s nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ethical principles with the LPN? a. Veracity b. Justice- c. Fidelity d. Nonmaleficence nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Use root cause analysis to identify gaps in meeting standards- root cause analysis is done if the benchmark is not met b. Establish work initiatives to promote a positive environment c. Compare practices within the facility against other high-performing facilities d. Determine how current practice will affect future performance within the facility 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. Place a faulty equipment tag on the pump b. Notify the provider c. Auscultate the client‟s lungs d. Complete an incident report client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? a. “It‟s not too late to cancel the surgery if you want to” b. “Why did you make the decision to have this procedure?” c. “This won‟t take long and it will be over before you know it” d. “You shouldn‟t be worried because the procedure is very safe” facility infection control nurse is reviewing the reports of a group of clients. Which of the following infections should the nurse report to the public health department? a. Lyme disease b. Bacterial conjunctivitis c. Health care-acquired pneumonia d. MRSA nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? a. The steps to follow when providing wound care b. The client‟s preferred time for bathing c. The belief that the client has a difficult relationship with his son d. The time the client received his last dose of pain medication nurse receives a new prescription over the telephone from a client‟s provider. Which of the following actions should the nurse take first a. Write down the complete prescription b. Read back the prescription to the provider c. Document the prescription as a telephone prescription in the medical record d. Ensure that the provider signs the prescription charge nurse witnessed an assistive personnel failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? a. Discuss the issue with the AP b. Notify the unit manager about the incident c. Reinforce facility protocols at the next staff meeting d. Alert the infection control department nurse is planning care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? a. Raise all four side rails on the client‟s bed b. Remove the clock and calendar from the client‟s room c. Obtain a prescription for a sedative for the client d. Provide distractions for the client during the day nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? a. Initiate contact precautions (standard) b. Report the infection to the local health department c. Apply an antiviral cream to lesions d. Instruct the client to use condoms until the treatment is completed (NO, not 100% preventable) nurse is teaching a class of newly licensed nurses about evidence-based practices. The nurse should include which of the following as the first step in evidence-based practice? a. Apply research to client care practice b. Develop a clinical question c. Critically assess the evidence d. Collect evidence from a variety of sources nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualty incident in the community. As clients arrive at the designed triage area outside the hospital, which of the following actions should the nurse take? a. Place shower caps over the client's‟ hair b. Remove contaminated clothing c. Scrub the client‟s skin with betadine solution d. Admit the injured clients to positive-pressure rooms case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Libel b. Negligence c. Battery d. Slander nurse is preparing to complete morning assignments on several assigned clients. Which of the following clients should the nurse plan to assess first? a. A client who had a bladder scan that indicated 250 mL of urine in the bladder b. A client who is 3 days postoperative and who‟s dressing has serosanguinous drainage c. A client who has diabetes and an early morning blood glucose of 220 mg/dL d. A client who has a nasogastric tube to intermittent suction and reports nausea charge nurse overhears a staff nurse discussing a client‟s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? a. “Please stop discussing the client in a public area” b. “Do you understand the HIPAA regulations?” c. “We should discuss your concerns with the client‟s care team” d. “I will notify the client‟s provider about this breach of confidentiality nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? a. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape b. Uses sterile forceps to pack sterile gauze into the wound c. Sets up the sterile field 30min prior to performing the dressing change d. Uses a sterile-gloved hand to adjust the back of the sterile gown. nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? a. Place the client in a negative-pressure airflow room b. Perform hand hygiene with alcohol based hand sanitizer. c. Clean the equipment in the client‟s room with bleach. d. Initiate droplet precautions for the client. nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate? a. Advise him to complete the less time consuming tasks first b. Recommend that he take time to plan at the beginning of his shifts c. Offer to provide care for his clients while he take a break d. Ask other staff members to take over some of his tasks nurse is planning discharge for a client who has lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral? a. The client needs to have someone bring O2 tanks and equipment to her home b. The client needs to have range-of-motion exercises to assist with ambulation c. The client needs to arrange financial resources to purchase equipment d. The client needs to have someone come in to help her bathe at home nurse initiates a referral to an occupation therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for this referral? a. The client reports pain when chewing solid foods. b. The client expresses the desire to join a support group. c. The client requires assistance with completing oral hygiene d. The client has difficulty ambulating with a walker nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client‟s care? (SATA) a. Nutritional therapists b. Case Manager c. Mental Health counselor d. Occupational therapist e. Physical therapist nurse is prioritizing care after a receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? [repeat] a. A client who reports a headache with sensitivity to light. b. A client who reports feeling lightheaded when he stands up from a lying position c. A client who reports indigestion and pain in her jaw d. A client who reports an urge to void but has not urinated during the prior shift nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority? a. A client who has depressive disorder and has poor personal hygiene b. A client who has dementia and exhibits aphasia c. A client who has bipolar disorder and displays constant pacing – (Can lead to physical exhaustion and death) d. A client who has schizophrenia and uses neologisms nurse is planning care for a group of clients. Which of the following action should the nurse take first? a. Obtain a breakfast tray for a client whose total parenteral nutrition was discontinued 4 hrs ago. b. Auscultate the bowel sounds of a client who has not had bowel movement after taking a laxative 12hr ago. c. Provide instruction to the caregiver of a client who has dementia and new diagnosis of diabetes mellitus. d. Check a client who has a leg cast and reports a new onset of pain. nurse on a med surg unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make? a. “You must choose a member of your family to serve as a your health care proxy.” b. “A health care proxy can make decisions for you when you are unable to do so.” c. “You should appoint a health care proxy before undergoing an invasive procedure.” d. “It is necessary for an attorney to approve your health care proxy.” nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, “I‟ve never taken these before.” Which of the following actions should the nurse take first? a. Consult the pharmacist about the client‟s prescribed medications. b. Compare the client‟s medication administration record with the prescriptions on the transfer orders. c. Review the intended purpose of the prescribed medication with the client. d. Call the provider to clarify the clients prescribed medications. nurse on a med surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who is postoperative following laminectomy 12hrs ago is unable to void b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy c. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot d. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38C (101F) nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? a. Plan to administer an antiviral medication to the client. b. Wear an N95 respirator mask while caring for the client. c. Prepare to administer antibiotics to the client. d. Place a surgical mask on the client during transfer to the unit. charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? [repeat] a. Discuss the time management strategies with the nurses b. Review facility policies for taking scheduled breaks. c. Provide coverage for the nurses‟ breaks d. Determine the reasons the nurses are taking scheduled breaks. nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a. False imprisonment b. Libel c. Assault d. Battery nurse is speaking with a visitor who asks a questions about the status of a relative who is a fadovclient on the unit. Which of the following responses by the nurse is appropriate? a. “I‟m not taking care of your relative today, so I don‟t have the latest information” b. “I will have your relative‟s nurse come and talk with you about her care.” c. “Let me check your relative‟s medical record to see how she‟s doing.” d. “Please ask your relative about this, because I cannot share information about her.” nurse suggests respite care for the partner of a client who has mild cognitive impairment. The client‟s partner asks the nurse how that would help. The nurse should explain the respite care would do which of the following? a. Allow her to take time off from attending to her partner b. Provide volunteers who will run errands for her c. Send a clinician to assess the safety of leaving her partner alone d. Help her arrange transferring her partner to an assisted living facility charge nurse observes a client fall during ambulation and notes that his gait belt was not in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the following ethical principles should guide the nurse‟s subsequent actions? a. Non maleficence - do no harm b. Veracity - commitment to tell the truth c. Fidelity - keep promises d. Beneficence - promote good for others HESI LEADERSHIP 4 5. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the following statements by a staff nurse indicate understanding of the teaching (SATA). • “I will attend continuing education classes for professional growth.” • “I can delegate the removal of an IV catheter to an LPN on the unit.” • “I administer pain medication to my clients even if they have a history of narcotic addiction.” 6. A nurse is discussing advance directives with a client. Which of the following statements by the client indicates an understanding of advance directives? • “I know I have the right to determine if I remain on a breathing machine.” 7. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the following findings indicated the need for referral to a wound care specialist? • Presence of slough in the wound bed 8. A nurse on a medical-surgical unit delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel? • Suctioning a client‟s long-term tracheostomy 9. A nurse is providing teaching about infection control measures to a client who has an indwelling urinary catheter. Which of the following instructions should the nurse include in the teaching? • Use sterile technique to collect specimens from the drainage system 10. A nurse manager is preparing an in-service for a group of staff nurses about organ donation. Which of the following information should the manager include? • Nurses may witness the signing of organ donation consents 11. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response? • “It‟s not too late to cancel the surgery if you want to.” [repeat] 12. A charge nurse is observing a newly licensed nurse insert an NG tube and connect it to a suction source. Which of the following actions by the newly licensed nurse demonstrates an understanding of the process? • Clamps the air vent tubing 13. A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority? • A client who has soot markings around each naris following a house fire 14. A nurse receives change-of-shift report for the following four clients. Which of the following clients should the nurse assess first? • An older adult client who has bacterial pneumonia and a new onset of restlessness 15. A charge nurse is making assignments for a medical surgical unit. Which of the following clients is appropriate to assign to a licensed practical nurse? • A client who has emphysema and has oxygen saturation of 92% 16. A nurse is admitting a client who is scheduled for cholecystectomy. The client does not speak English and is accompanied by her adult daughter. Which of the following actions should the nurse take? • Access a language line to interpret what is being said 17. A nurse is caring for a client who has an MI. The client‟s daughter ask the nurse to review her father‟s medical with her. Which of the following responses should the nurse make? • “Your father will have to give permission for you to review the record.” 18. A nurse is teaching a client who requires protective isolation due to immune system compromise. Which of the following instructions should the nurse include to protect the client? “Make sure your visitors wear a gown when they are in your room.” “Wear gloves and a gown whenever you need to leave your room.” “Be sure to eat plenty of fresh fruit and vegetables.” 19. A nurse in the emergency department is preparing a married 17-year-old client for an appendectomy. The client‟s parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take? • Have the client sign the consent form after the surgeon explains the procedure 20. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? • “I understand, and it‟s not too late to change your mind.” 21. A nurse is completing discharge teaching with a client who is being treated with tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? • “I should have a sputum culture done every 2-4 weeks” 22. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client‟s need for which of the following to manage the tracheostomy at home? (SATA) • Obturator • Oxygen tank • Suction machine 23. A nurse is completing discharge teaching about dietary supplements for nitrogen loss with a client who has cancer. Which of the following nutrients should the nurse recommend the client increase? • Protein 24. A case manager is preparing a client who has a spinal cord injury for discharge from the rehabilitation setting to home. Which of the following actions is the case manager‟s priority when creating the discharge plan? • Facilitate client referrals for community resources 1. A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first? o Establish measurement criteria for infant safety systems. o Evaluate the selected infant safety system. o Choose an infant safety system. o Identify the industry standards for infant safety. 2. A nurse at a local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? o Chlamydia trachomatis o Pediculosis capitis o Impetigo contagiosa o Candida albicans 3. A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department. o Candidiasis o Gonorrhea o Trichomoniasis o Human papillomavirus 4. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? o Review with the nurse principles of medication administration. o Ask the nurse to describe the medication administration procedure. o Identify education opportunities for the nurse regarding safe medication administration. o Notify the risk management department of the situation. 5. The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make the health care decision? o The provider o The oldest adult child o The partner o The client 6. A nurse is working with a committee that is performing an annual review of policies and procedures. After gathering data, identify the sequence the committee should follow when using the stages of change. (put in order) o Determine goals 1 o Create a revised protocol 2 o Implement the revised protocol 3 o Review the results of the provisions. 4 7. A nurse is providing a change of shift report for the oncoming nurse. Which of the following information should the nurse include in the report? o “ The client‟s partner came to visit him 2 hours ago and smelled of alcohol.” o “ The client is the president of a local bank.” o “ The client will need vital signs checked every 4 hours.” o “ The client is currently in the radiology department for a chest x-ray.” 8. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? o Child protective services o Pharmacist o Social worker o Respiratory therapist 9. A nurse is preparing a shift assignment for an assistive personnel on the unit. Which of the following tasks should the nurse assign to the AP? o Check a client‟s pain level 30 min after receiving acetaminophen o Administer the initial bolus feeding to a client who has an NG tube o Collect a urine specimen from a newly admitted client o Instruct a client to splint an abdominal incision 10. A nurse is teaching a class of newly licensed nurses about evidence- based practice. The nurse should include which of the following as a first step in evidence-based practice. o Collect evidence from a variety of sources o Develop a clinical question o Apply research to client care practice o Critically assess the evidence 11. A nurse is inspecting a clients IV pump prior to use. The nurse should tag and report which of the following safety hazards? o The electrical cord is taped to the floor o The IV pump is plugged into an outlet close to the bed o The IV pump has a free-flow protective device o The electric plug has two short prongs – (Must be 3 prongs) 12. A nurse who is caring for a group of clients, delegates collection of vital signs to an assistive personnel. Which of the following actions should the nurse take to evaluate the delegated task? o Recheck vital signs that are outside the expected reference range o Review the vital sign trends at the end of the shift. o Ask the AP to write a summary of the delegated tasks during the shift. o Compare the vital signs the AP obtained with those taken by another AP on a previousshift. 13. A nurse is caring for a client who has signed consent for the removal of the tumor in the left frontal lobe of the brain. The client states, “The tumor is on the right side of my head.” Which of the following actions should the nurse take? o Continue with the surgery because the client already gave informed consent. o Ask the surgeon to clarify the operative site with the client o Contact the surgery department to validate the operative site o Tell the client to mark the right side of his head with indelible ink 14. A nurse is preparing to witness a client‟s signature on an informed consent for a surgical procedure. Which of the following actions is the nurse‟s responsibility? o Ensuring the client appears competent to consent to the procedure o Discussing options for the alternative therapies with the client o Providing the client with a complete description of the procedure o Explaining the risks associated with the procedure to the client 15. A charge nurse witnesses two nurses having a loud discussion at the nurses‟ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? o Make arrangements to take over the clients care. o Contact the house supervisor to mediate the conflict o Escort the nurses to the nurses lounge to continue the discussion o Recommend that both nurses are terminated 16. A nurse is observing an assistive personnel administer 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? o Inserts the tubing 8 cm (3.1 in) into the rectum o Positions the client on her left side with knees flexed o Points tubing in the direction of the umbilicus during insertion o Administers the solution at room temperature Rationale: Prepare and warm the enema solution. Position the client on the left side with the right leg flexed forward. Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). 17. A nurse is prioritizing care after receiving report on four clients. Which of the following clients should the nurse assess first? o A client who reports feeling lightheaded when he stands up from a lying position o A client who reports an urge to void but has not urinated during the shift prior o A client who reports indigestion and pain in her jaw o A client who reports a headache with sensitivity to light 18. A charge nurse is directing the unit nurses to implement the emergency response plan for a fire on the unit. Which of the following instructions should the charge nurse give to the unit nurses? o Ask ambulatory clients to help move clients in wheelchairs to safety o Continue therapy for clients who are receiving oxygen o Close the doors of the unit before moving clients to a safe place o Maintain mechanical ventilation for clients who are on life support. 19. A nurse is providing teaching to an older adult client regarding home safety. Which of the following instructions should the nurse include in the teaching? o Cover chords with the carpet to prevent falls o Unplug humidifier before cleaning it o Change batteries in the smoke alarm every 2 years o Set the water heater to 60 degrees C (140 F) 20. A nurse is using the SBAR communication tool while giving report on a client. The nurse should include the client‟s pain level after receiving a PRN dose of morphine 1 hr ago during which part of the report? o A-assessment o B-background o R-recommendation o S-situation 21. A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using? o Benchmarking o Structure audit o Risk benefit analysis o Root cause analysis 22. A nurse is planning a discharge for a client who has a new diagnosis of COPD and lives alone. Which of the following actions is the nurse‟s priority? o Provide printed materials for new prescriptions o Set up appointments in in-home physical therapy o Request a referral for a home safety assessment o Suggest participating in a community group 23. A nurse is caring for a group of clients. Which of the following clients should the nurse see first? o A client who is postoperative and has a fever (nonurgent) o A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to10 o A client who has pressure ulcer has serosanguineous drainage on the dressing o A client who has diabetes mellitus and is diaphoretic 24. A nurse manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as an HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? o Negligence o Battery o Libel o Slander 25. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for the referral? o The client has difficulty ambulating with a walker o The client requires assistance with completing oral hygiene o The client reports pain when chewing on solid foods o The client expresses desire to join a support group 26. A home health nurse finds piles of newspaper in the hallway of a client‟s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? o Compromising o Smoothing o Collaborating o Accommodating 27. A nurse reports to a charge nurse that a client‟s visitor slipped and fell. The visitor denies any injury and is walking around. Which of the following instructions should the charge nurse give the nurse? o “ Have the visitor sign a waiver” o “ Document the incident report in the client‟s medical record” o “Offer the visitor an analgesic” o “ Record the event on an occurrence report” 28. A nurse is preparing an education program about professional codes of ethics for nurses. Which of the following information should the nurse plan to include? o A code of ethics is a step-by-step approach to decision making o A code of ethics is legally binding o A code of ethics outlines the nurses scope of practice o A code of ethics is a set of principles for nursing practice 29. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? o Rotavirus o Rubeola o Varicella o Mumps 30. A nurse manager discovers there is a conflict between nurses working day shift and working night shift. Which of the following actions should the nurse take? o Gather information regarding the situation o Acknowledge the conflict and encourage the nurses to focus on working as a team o Encourage the nurses to resolve the conflict autonomously o Meet with the a committee of nurses from each shift to discuss issues related to the conflict 31. 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? o The nurse puts on a face mask o The nurse applies goggles o The nurse holds her hands above her waist o The nurse turns her back to the sterile field 32. A nurse in an emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? o An adolescent who has an injured ankle and reports a pain level of 8 on a scale of 0-10 o A toddler who has a 2cm (0.79 in) head laceration oozing dark red blood o An older adult client who has dyspnea and a respiratory rate of 26min o An adult client who has large ecchymoses on both legs 33. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? o Pharmacist o Occupational therapist o Respiratory therapist o Physical therapist 34. A nurse in a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include? o Accompany residents older than 85 years of age during ambulation o Institute rounds every 2 hr during the day to offer toileting o Keep the four side rails up on beds at night o Apply vest restraints on residents who are confused 35. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change of shift report? o The time the client received his last dose of pain medication o The clients preferred bath time o The belief that the client has a difficult relationship with his son o The steps to follow when providing wound care 36. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? o An adult client who has moderate Alzheimer‟s disease o An older adult client who has questions about the procedure o An adult client who has alcohol intoxication o An adolescent client who is legally emancipated 37. A nurse is completing a performance evaluation for an assistive personnel. Which of the following actions by the AP requires intervention by the nurse? o The AP wears a mask when caring for a client who has varicella o The AP removes cut flowers from the room of a client who is in a protective environment o The AP closes the door of a client who is on airborne precaution o The AP uses alcohol hand antiseptic after caring for a client who has C-Diff 38. A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee? o A young adult client who is participating in a medical research study o An older adult client who has advance directives on file o An adolescent client whose parents refuse a blood transfusion for religious reasons o A middle adult client who leaves the facility against medical advice 39. A nurse is working with a licensed practical nurse (LPN) to care for a group of clients. Which of the following clients should the nurse delegate to the LPN? o A client who has leukemia and requires an updated plan of care o A client who is transferring from the PACU following abdominal hernia repair o A client who has type 1 diabetes mellitus and receives insulin before meals o A client who requires discharge teaching about a newly described medication- 40. A nurse is coordinating an interprofessional team to review proposed standards to reduce the transmission of MRSA. Which of the following members of the interprofessional team should the nurse consult? o Infection control nurse o Nursing supervisor o Risk management coordinator o Clinical pharmacist 41. A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions should the nurse include as an example of ethical practice? o A nurse raises all four side rails on the bed of a client who is confused o A nurse refuses to care for a client who has had an abortion o A nurse withholds nutrition from a client who has DNR order - don‟t do this... o A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min. 42. A nurse is conducting an in service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? o Evaluating a client‟s home for safety hazards o Recommending a referral for a client who requires physical therapy o Completing an incident report following a medication error o Suggesting a client‟s partner attend a support group for emotional support 43. 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? o Notify the provider o Place a faulty equipment tag on the pump o Auscultate the client‟s lungs o Complete and incident report 44. A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation? o Document in the incident report, „ Entered room and discovered client lying prone on the floor‟ o Document in the nurses report, „Photocopy of incident report sent to risk management‟ o Document in incident report, „Client found lying on the floor after falling out of bed‟ o Document in nurses notes, „Incident report completed and filed‟ 45. A nurse is planning discharge teaching for a client who has a newly placed tracheostomy tube. The nurse should assess the client‟s need for which of the following supplies to manage tracheostomy at home? (SATA) o Cotton-twill tracheostomy ties o Suction machine o Povidone – iodine swabs o Petroleum jelly lubricated gauze o Oxygen tank 46. A nurse is providing discharge teaching to a client following total knee arthroplasty. Which of the following information should the nurse include? (SATA) o Information about follow up care o Medication guideline information o Advance directives information o Contact information for the physical therapist o Insurance information 47. A charge nurse overhears a staff nurse discussing a client‟s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? o “ We should discuss your concerns with the client‟s care team” o “ I will need to notify the client‟s provider about the breach of confidentiality” o “ Please stop discussing the client in a public area” o “ Do you understand HIPAA regulations?” 48. A nurse is caring for a client who reports taking a new herbal supplement after reading about it on the Internet. Which of the following instructions should the nurse provide the client? o Compare website‟s information with a variety of sources o Look for medical information on network (. Net) websites o Ensure the website is sponsored by a pharmaceutical company o Consider the Internet information reliable if it is written by a doctor 49. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? o Veracity – nurse’s duty to tell the truth o Nonmaleficence – nurse’s obligation to avoid causing harm to the client o Utility o Autonomy – the ability of the client to make personal decisions 50. A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take? o Tell the client to leave her purse in a drawer of the bedside table o Place the purse in the clothing bag with the clients belongings o Offer to place the purse in the facility‟s safe o Offer to store the purse in the nurses station 51. A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse is appropriate? o Elevating the head of the bed 20 degree angle o Check residual volume before each feeding o Flushing The tube with 15 mL of water o Adding colored food dye to the formula 52. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the client‟s risk of falls? (SATA) o A throw rug covering some cracked vinyl flooring in the kitchen o A folding chair without arm rests o A two- wheeled walker used to assist the client with ambulation o A raised vinyl seat on the toilet in the client‟s bathroom o A wheeled office chair at the client‟s computer desk 53. A nurse on a medical- surgical unit is caring for a client who asks about advance directives and states the he wants to appoint a health care proxy. Which of the following responses should the nurse make? o “ It is necessary for an attorney to approve your health care proxy” o “ A health care proxy can make decisions for you when you are unable to do so” o “ You must choose a member of your family to serve as your health care proxy” o “ You should appoint a health care proxy before undergoing an invasive procedure” 54. A nurse is preparing to transfer a client to the radiology department using the wheelchair. Which of the following actions should the nurse take? o Push the wheelchair into the elevator, large wheels last/ o Leave a transfer belt in place until the client returns from radiology o Keep the footplates lowered throughout the transfer process. o Test the locks on both wheels of the chair prior to transfer. 55. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? o “A nurse can apply restraints on a PRN basis” o “A nurse can administer medications without consent to a client as part of a research study” Patients have right to refuse o “A nurse can disclose information to a family member with the client‟s permission.” o “A nurse is responsible for informing clients about treatment options” 56. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? o Assign clients who are not prescribed narcotics to the staff nurse o Counsel the staff nurse about substance abuse use o Collect data about the staff nurse to support further action Always assess first o Report the staff nurse to the facility ethics committee 57. A charge nurse is admitting a client who speaks a different language than the nurse and will require and interpreter. Which of the following actions should the nurse plan to take? o Limit interpreter services to daytime hours o Repeat the same words to the interpreter if the client does not understand o Assign a bilingual staff member to be the interpreter when caring for the client o Pause in the middle of the sentence when using an interpreter 58. A nurse is caring for a client who has Addison‟s disease. Which of the following tasks should the nurse plan to delegate to an assistive personnel? REPEAT QUESTION o Explain to the client about a 24hr urine specimen collection RN o Determine the client‟s muscle strength prior to ambulation RN o Decide how often to measure vital signs RN o Remind the client to change positions slowly within AP scope 59. A nurse is caring for a client who had a stroke and is experiencing difficulty swallowing. The nurse should arrange a referral to which of the following members of the interprofessional team regarding the client‟s condition? o Speech pathologist– Evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing o Occupational therapist o Physical therapist o Social worker 60. A nurse is planning care for four clients who were classified using a disaster triage tag team system following a mass casualty event. Which of the following clients should the nurse identify as priority? o A client who has a red tag o A client who has a yellow tag (delayed – serious but not life threatening) o A client who has a green tag (minor, walking wounded) o A client who has a black tag 61. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? o File an incident report o Ask the client about his injuries with the son present o Treat and discharge the client o Ask the client‟s son to wait in the waiting room 62. A charge nurse is reviewing the actions by a nurse following a client fall. Which of the following actions by the nurse requires intervention by the charge nurse? o Lists names of witnesses to the fall in the incident report o Documents in the client‟s record, “Incident report was filed” o Sends the incident report to risk management o Includes the client‟s account of the fall in the incident report 63. A nurse on a medical-surgical unit is making staff assignments. Which of the following tasks should the nurse delegate to an assistive personnel? o Pouching a client‟s established ostomy o Reinforcing teaching with a client about low-sodium diet o Demonstrating the use of an incentive spirometer to a client o Updating a family member about a client‟s condition 64. A nurse is caring for a client who is scheduled for placement of central venous access device. Which of the following actions is the nurse‟s responsibility in the informed consent process? o Discuss alternative treatment options with the client o Place a photocopy of the signed informed consent in the client‟s medical record - o Assess the client‟s understanding after the provider has talked to her o Review the risks and benefits of the procedure with the client 65. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? o “ A provider can write a prescription for restraints „as needed‟ o “ I should tie the restraints using a square knot” o “ I need to tie the restraint to the part of the bed frame that moves” o “ I will remove the client‟s restraints every 4 hours” 66. A nurse is receiving change of shift report for four clients. Which of the following clients should the nurse care for first? o A client has pneumonia and requires a tracheostomy dressing change o A client has a new colostomy and requires discharge teaching o A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea o A client who is 4 hours postoperative following a hernia repair and has pitting edema of the right leg – (Compartment syndrome) 70. A nurse is assessing a client who has meningitis. Which of the following finding should the nurse report to the provider immediately? o Increased temperature o Report of photophobia o Decreased level of consciousness o Generalized rash over trunk HESI LEADERSHIP 5 3. A nurse should recognize that an incident report is required when a. A client refuses to attend physical therapy. 
 b. A visitor pinches his finger in the client‟s bed frame. 
 c. A client throws a box of tissues at a nurse. 
 d. A nurse gives a medication 30 min late. 
 Rationale:HESI Leadership Page 95 4. MISSING 
 5. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr post operatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery? a. Prospective chart audit 
 b. Retrospective chart audit 
 c. Postoperative care policy 
 d. Pain assessment policy 
 Rationale:HESI Leadership Page 19 6. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask? a. “Did you secure the restraints to the side of the rails of the bed?” 
 b. “Are you able to slip two fingers between the restraints and the client‟s skin?” 
 c. “Did you tie the restraints using a double knot?” 
 d. “Are you removing the client‟s restraints every 4 hours?” 
 Rationale: HESI Leadership Page 81 7. A nurse is caring for an older adult client who has a stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? 
 a. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation. b. Provide the consultant with subjective opinions and beliefs about the client‟s wound care. c. Request the consultation after several wound care treatments are tried.
 d. Arrange for the wound care nurse specialist to see the client daily to provide the recommendation treatment. Rationale: HESI Leadership Page 40 8. A client is admitted with tuberculosis and placed in a negative pressure room. Which of the 
following nursing actions is appropriate? a. Notify the local health department of the admission. 
 b. Place a sign on the client‟s door with the diagnosis 
 c. Ensure that admitting staff undergo PPD skin tests. 
 d. Determine who had contact with the client in the last 48 hr. 
 Rationale:HESI Leadership Page 62 9. A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client‟s feeding tube. The provider states to the nurse, “I will not discontinue this client‟s treatment. His partner has no right to make decisions regarding the client‟s care.” Which of the following responses by the nurse is appropriate? a. “You should consider speaking with the facility‟s ethics committee before making your decision.” 
 b. “You have the right to make that decision, even if the partner is the client‟s health care proxy.” 
 c. “The client has designated his partner as health care proxy in his advanced directives.” 
 d. “We‟ll need to have the nursing supervisor review the client‟s advanced directives.” 
 Rationale: HESI Leadership Page 54 10. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change? a. Glasgow coma scale score 
 b. Most recent blood glucose reading 
 c. Laboratory tests scheduled for next shift 
 d. Reddened area on the coccyx 
 Rationale: HESI Leadership Page 6 11. A nurse is assigned the four following client‟s for the current shifts. Which of the following clients should the nurse assets first? a. A client who has a hip fracture and is in buck‟s traction 
 b. A client who bas aspiration pneumonia and a respiratory rate of 28/min 
 c. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot 
 d. A client who has a clostridium difficile infection and needs a stool specimen collected 
 Rationale: HESI Leadership Page 7 12. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take? a. Notify the nursing supervisor about the issue 
 b. Contact the client‟s physical therapist 
 c. Apply a warm compress to the hip 
 d. Reposition the client for comfort 
 Rationale: ATI page 15 13. The mother of a client with breast cancer states, “It‟s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments.” Which of the following actions is appropriate client advocacy? 
 a. The nurse investigates potential resources to help the client purchase a wig b. The nurse explains to the mother that most client‟s with cancer lose their hair 
 c. The nurse informs the next shift nurse regarding the mother‟s concerns 
 d. The nurse suggests counseling for the client‟s body image issues 
 Rationale: HESI Leadership Page 51 14. Which of the following items must be discarded in a biohazard waste receptacle? a. A urinary catheter drainage bag from a client who is postoperative 
 b. A bed sheet from a client with bacterial pneumonia 
 c. A perineal pad from a client who is 24 hr post vaginal delivery 
 d. An empty IV bag removed from a client who has HIV 
 Rationale:HESI Leadership Page 75 15. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don‟t get better, I‟m going to quit.” Which of the following responses by the unit manager is appropriate? a. so you are upset about all the changes on the unit 
 b. I think you have a right to be upset. I am tired of changes too 
 c. just stick with it a little longer. Things will get better soon 
 d. you should file a written complaint with hospital administration 
 Rationale: HESI Leadership Page 23 16. According to HIPPA regulation, which of the following is a violation of client confidentiality?` a. telephoning the pharmacy with a prescription for the spouse to pick up 
 b. providing a copy of the record to the transporting paramedi c 
 c. reporting a client‟s disposition to the referring provider 
 d. informing housekeeping staff that the client is in the dialysis unit. 
 17. A nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with sterile procedure. Which of the following actions indicates the nurse is maintaining sterile techniques (select all that apply)` a. opens the sterile pack by first unfolding the flap farthest from her body 
 b. rests the cap of solution container upside down on the sterile field 
 c. holds a bottle of sterile solution 15cm (6 inches) above the sterile field d. Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field. 18. A nurse is providing care for four postoperative clients. The nurse should assess the client` a. whose pulse has been steadily increasing during the past shift 
 b. who is reporting pain level of 8 on a scale of 0-10 
 c. whose urine output has averaged 32ml/hr for the past 24hrs 
 d. Who is reporting nausea after the prescribed antiemetic was administered 
 19. A nurse is preparing to transcribe a client‟s medication prescription in the medical record. Which of the following should the nurse recognize as containing the essential components o f a medication order a. NPH insulin 10 units before meals and at bedtime 
 b. Haloperidol(Haldol)1mgbymouth 
 c. Multivitamin every morning by mouth 
 d. Aspirin 650mg by mouth every 4 hours 
 20. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?` a. Recommend that he take time to plan at the beginning of his shift b. Advise him to complete less time consuming tasks first 
 c. Ask other staff members to take over some of his tasks 
 d. Offer to provide care for his clients while he takes a break 
 21. A nurse is in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first?` a. Remove the clients clothing b. Irrigate the exposed area with water c. Report the incident to OSHA d. Don personal protective equipment 22. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed` a. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client 
 b. A nurse gives prescribed opioids to a client who has terminal illness and respirations of 8/m 
 c. A nurse explains to a client‟s family that DNR orders includes withholding comfort measures d. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better 23. A nurse in an ambulatory care setting is orienting 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 teleheath` a. Assessing client needs 
 b. Providing medication reconciliation 
 c. Establishing communication between providers 
 d. Developing client treatment protocols 
 24. Which of the following puts a hospital at the highest risk for infringement of client record confidentiality?` a. A nurse clusters documentation of care for multiple clients 
 b. A provider and nurse access client information using one access code 
 c. Paper based charts are stored at the nurse‟s station 
 d. A nurse performs electronic documentation outside a client‟s room 
 25. Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques` a. A nurse cleans up a blood spill with a 1:10 bleach solution 
 b. A nurse uses goggles to perform tracheostomy suctioning 
 c. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen d. A nurse places a mask on a client with tuberculosis before transport to the radiology department 26. Which of the following should lead a nurse to suspect abuse that must be reported?` a. A school age child has several bruises on her lower legs 
 b. A toddler cries whenever his parent enters the hospital room 
 c. An adolescent admitted to the emergency department won‟t speak to his parents d. A preschool child who previously toilet trained now requires diapers in the hospital 27. A parish nurse is making referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse` a. Liaison 
 b. Pastoral care provider 
 c. Health educator 
 d. Personal health counselor 
 28. A nurse performing triage during a mass casualty incident should recognize that which of the following clients should be transported to the hospital first` a. A client who reports substernal chest pain radiating to the neck 
 b. A client who has an open fracture of the femur 
 c. A client who has a 4 inch laceration on the forearm 
 d. A client who has a penetrating head injury and fixed and dilated pupils 
 29. MISSING 30. A nurse manager over hears a provider and a staff nurse talking about a client‟s diagnosis in the cafeteria. Which of the following actions should the nurse take first? a. Provide a staff in-service about client confidentiality. 
 b. Report the incident to the nursing supervisor 
 c. Remind them that client information is confidential 
 d. Fill out an incident report regarding the situation. 
 31. A client who has substance use disorder is admitted to the mental health unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states, “It‟s okay. Soon everything will be just fine.” Which of the following is the nurse‟s priority action?` a. Ask the client if he has considered hurting himself. 
 b. Provide the client with information about Alcoholics Anonymous 
 c. Encourage the client to participate in physical activities 
 d. Reinforce the need to follow up with discharge referral. 
 32. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a. False imprisonment 
 b. Battery 
 c. Assault 
 d. Libel 
 33. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first?` a. Report the situation to the director of nursing 
 b. Have a blood alcohol level drawn from the nurse. 
 c. Document a factual description of the situation. 
 d. Remove the nurse form the unit. 
 34. A nurse observes a paper bag at the bedside of a client. The finding suggests that a client is receiving treatment for which of the following respiratory disorders? 
` a. Asthma 
 b. Hyperventilation 
 c. Stridor
 d. Atelectasis 
 35. A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?` a. Laboratory results within the expected reference range 
 b. List of regularly prescribed medications 
 c. Date of last bowel movement 
 d. Level of consciousness 
 36. 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. Review the client‟s new laboratory values. 
 b. Document assessment data. 
 c. Complete required tasks 
 d. Determine client care goals. 
 37. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines? a. “I will instruct visitors to wear a mask when visiting a client who is on contact precautions.” 
 b. “I will place a client who has compromised immunity in a negative-pressure airflow room.” 
 c. “I will wear a N95 respirator mask when caring for a client who is on droplet precautions.” 
 d. “I will have a client who is on airborne precautions wear a mask when out of her room.” 38. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse? a. Changing the dressing on a postoperative wound 
 b. Referring to a client to social services for assistance with transportation 
 c. Instructing a client who is obese with a low-fat diet 
 d. Providing the first oral feeding to a client following a stroke 
 39. A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury at vertebral level C-7. Which of the following is the priority action when creating the discharge plan? REPEAT a. Select strategies for cost-effective home care. 
 b. Identify the client‟s ability to perform activities of daily living.
 c. Provide educational handouts related to care requirements. 
 d. Recommend community resources available to assist with client care. 
 40. A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse plan to assess first? REPEAT a. A client who has a nasogastric tube to intermittent suction and reports nausea b. A client who has an early morning blood glucose of 220 mg/dL 
 c. A client who had a bladder scan that indicated 250 mL of urine in the bladder d. A client who is 3 days postoperative and whose dressing has serosanguinous drainage
 41. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? REPEAT a. Plan break times for assistive personnel. 
 b. Pick up the meal trays after lunch. 
 C. Administer a nasogastric tube feeding.
 d. Determine adequacy of ventilator settings. 
 42. A RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires REPEAT a. Recording of daily intake and output 
 b. Assistance with meals 
 c. A complete bed bath 
 d. Frequent dressing changes.
 43. Missing 
 44. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel? a. Assessing a client who just returned from hemodialysis 
 b. Reviewing dietary instructions for a client with kidney stones 
 c. Obtaining a stool sample from a client with renal failure 
 d. Monitoring a client with a fluid restriction 
 45. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? a. Inform the unit manager of the incident 
 b. Remove the restraints from the client‟s wrists
 c. Speak with the AP about the incident 
 d. Review the chart for non-restraint alternatives for agitation 46. A client is brought to the emergency department (ED) 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. Document the client‟s refusal in the chart
REPEAT b. Tell the client that a catheter will be inserted 
 c. Obtain a provider‟s prescription for the blood alcohol level 
 d. Assess the client for urinary retention 
 47. Nurses on an in-patient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan? REPEAT a. Use clean gloves rather than sterile gloves for colostomy care 
 b. Wait to dispose of sharps container until they are completely full 
 c. Return unused supplies from the bedside to the unit‟s supply stock 
 d. Store opened bottles of normal saline in a refrigerator for up to 48 hr 
 48. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to an assistive personnel? REPEAT a. Turning the client 
 b. Recording the client‟s vital signs
 c. Determining the client‟s pain level 
 d. Checking the pulses of the client‟s right food 
 49. To resolve the conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using? 
REPEAT a. Compromising b. Collaborating c. Cooperating d. Competing 
 50. A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit? 
 a. A client who has gestational diabetes and is receiving biweekly nonstress tests b. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump c. A multigravida client who has preeclampsia and is receiving mistoprostol (Cytotec) for induction of labor d. A client who is at 32 weeks of gestation and has a premature rupture of membranes 51. A nurse working on a medical-surgical unit is managing care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients? a. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL 
 b. A client who has Type 1 diabetes and uses an insulin pump 
 c. A client who has orthostatic hypotension and is receiving IV fluids 
 d. A client who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80 sec) Rationale: https://quizlet.com/35490529/ati-normal-range-lab-values-flash-cards/ 52. A charge nurse is assessing staff knowledge about safety procedures regarding needle stick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? REPEAT a. “prophylactic treatment should be initiated after a needlestick during preparation of an injection.” 
 b. “I should stop the bleeding as soon as possible following a needlestick injury.” c. “an incident report should be completed if a client receives a stick from her own used needle.” d. “the needle should be recapped to prevent injury during transport to the biohazard container.” 53. A nurse on a medical-surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Obtaining a urine specimen from an older adult client 
 (AP/CNA) b. Providing postmortem care for a client who has just died 
 (AP/CNA) c. Accompanying a client who just had a wound debridement to physical therapy 
 (AP/CNA) d. Reinforcing dietary teaching with a client who has heart disease 
 54. A nurse enters the room of a client who is unconscious and finds that the client‟s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? REPEAT a. Recommend the son meet with the provider to get information about his mother‟s condition 
 b. Complete an incident report regarding the breach of the client‟s confidentiality 
 c. Log out the computer so that the client‟s son is unable to view his mother‟s information d. Report the possible violation of client confidentiality to the nurse manager 55. A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene? a. The oxygen machine has a grounded plug 
 b. The family keeps a spare oxygen tank in the room 
 c. The windows of the client‟s room are open 
 d. The client is covered with a woolen blanket 
 56. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? REPEAT a. Elevate the arm for 1 min before taking the blood sample 
 b. Cap the lancet prior to putting it in the trash 
 c. Obtain the blood sample from the finger pads 
 d. Warm the hands prior to piercing the skin 
 57. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? 
REPEAT a. Contact the client‟s next of kin to obtain consent for treatment b. Proceed with treatment without obtaining written consent c. Have the client sign a consent for treatment
 d. Notify risk management before initiating treatment 58. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? REPEAT a. The client should avoid using a microwave oven to heat food b. Regular programming evaluations can be conducted by telephone c. the client should avoid using remote control devices to prevent dysrhythmias d. Swimming could cause the unit to have an electrical short 59. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take? REPEAT a. Reinforce the potential consequences of not having this information on record to the nursing staff b. Ask nurses who are caring for clients without this information in the medical record to obtain it. c. Meet with the nursing staff to review the policy regarding advance directives d. Remind nurses to obtain this information during the admission process 60. A client is admitted with COPD. Which of the following findings should the nurse report to the provider? REPEAT a. Oxygen saturation 89% on room air
 b. White blood cell count 9,000/mm^3
 c. Report of dyspnea on exertion
 d. Bilateral crackles on auscultation of lungs 61. A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first? a. Providing coverage for the nurses‟ breaks b. Determining the reasons the nurses are not taking scheduled breaks c. Discussing time management strategies with the nurses d. Review facility policies for taking scheduled breaks 62. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client‟s care? (select all that apply.) REPEAT a. Occupational therapist b. Nutritional therapist c. Physical therapist d. Mental health counselor e. Case manager 63. 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? REPEAT a. “Guardian consent is required for an emancipated minor.” b. “Consent can be given by a durable power of attorney.” c. “A family member can interpret to obtain informed consent from a client who is deaf.” d. “The nurse can answer any questions the client has about the procedure” 64. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? REPEAT a. A client who is newly diagnosed with pancreatic cancer and scheduled to begin IV chemotherapy
 b. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot c. A client who is postoperative following a laminectomy 12 hours ago and is unable to void d. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38 C (101 F) 65. A client is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical units. Which of the following nursing statements is an appropriate nursing response? a. “It‟s not too late to cancel the surgery if you want to.” REPEAT b. “This won‟t take long and it will be over before you know it.” c. “Why did you make the decision to have this procedure?”
 d. “You shouldn‟t be worried because the procedure is very safe” 66. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority? a. A client who has a raised red skin rash on his arms, neck, and face
 b. A client who reports right-sided flank pain and is diaphoretic
 c. A client who reports shortness of breath and left neck and shoulder pain
 d. A client who has active bleeding from a puncture wound of the left groin area 67. A nurse is working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? REPEAT a. Review current literature regarding client falls b. Implement a fall prevention plan
 c. Notify staff of the increased fall rate d. Identify clients who are at risk for falls 68. A nurse is evaluating a newly licensed nurse who is administering a vitamin K. (Aquamephyton) injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (Select all that apply.) REPEAT a. Selects the dorsogluteal site to administer the injections b. Cleans the injection site with alcohol c. Applies gentle pressure at the site after injection d. Aspirates the syringe for blood return after needle insertion e) Inserts the needle at a 45 degree angle (90 degree) 69. A nurse enters a client‟s room and observes a fire in the trash can. Identify the sequence of actions the nurse should take. (Move all the actions into the box on the right, placing them in the selected order of performance.) REPEAT Activate the fire alarm system
 2 Confine the fire by closing doors and windows 3 HESI Leadership Exam 6 verbalize their objections and thereby discuss possible solutions. Encourage staff members who support the changes to discuss the issue with resistant staff is correct. Peers can serve as change agents and encourage others to embrace the changes. Suggest that resistant staff members transfer to a different unit is incorrect. This approach avoids conflict rather than attempting to resolve it. Reprimand staff members who are resistant to the changes is incorrect. Resistance to change is a normal part of the change process. The charge nurse should use positive strategies to aid in acceptance of the proposed change. A nurse is caring for a client who is 3 days postoperative following open heart surgery and is to transfer to the medical-surgical unit. Which of the following should the nurse plan to include in the verbal report? The client's level of consciousness A nurse case manager is planning a teaching session on use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following in the teaching about critical pathways? Critical pathways prevent unnecessary expense. Nurses use critical pathways to implement evidence-based strategies for clients who have a specific, common diagnosis. A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to a licensed practical nurse (LPN)? A client who has Crohn‟s disease and requires an enteral feeding A nurse manager is presenting an inservice about preventing readmission of clients due to complications after joint replacement surgery. Which of the following leadership tasks is the nurse performing? Advocacy A staff nurse at a long-term care facility is evaluating an assistive personnel (AP) caring for a group of clients who require restraints. Which of the following is an appropriate action by the AP? Placing the restraint tie on a moveable part of the bed frame not the side rails, to prevent constriction when changing the position of the bed. The nurse should secure mitten restraints at the client‟s wrist. An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge? Ensure that home infusion therapy has been arranged. A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an assistive personnel (AP)? (Select all that apply.) Flushing a client's saline lock is incorrect. This is not within the AP's scope of practice. Ambulating a client who uses a walker is correct. This is within the AP's scope of practice. Adding thickener to thin liquids on a client's food tray is correct. This is within the AP's scope of practice. Showing a client how to use an incentive spirometer is incorrect. This is not within the AP's scope of practice. Evaluating a client's gag reflex before mealtime is incorrect. This is not within the AP's scope of practice. A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which of the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence? Set a goal for improvement in adherence. A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no orthopedic experience. Which of the following clients should be assigned to the medical nurse? A client who had a right above-the-knee amputation 24 hr ago A nurse manager is coordinating staff assignments for RNs and licensed practical nurses (LPNs) following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care? LPNs provide care to class III (green tag) clients. LPNs can provide care for class III clients, who have nonurgent, minor injuries. Class IV clients are expected to die or have died. This would be an appropriate assignment for assistive personnel, not an RN. Class I clients require immediate attention typically due to airway obstruction or shock. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment. Class II clients require treatment within 30 min to 2 hrs. This would not be an appropriate assignment for the LPNs due to the need for an initial nursing assessment. A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next? Inform the client about the risks she may encounter by leaving the facility. A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives? "A family member of a client can have the living will overturned in some cases." A charge nurse is performing chart reviews on infection control precautions implemented by nursing personnel during the admission of clients to the unit. Which of the following is an appropriate infection control precaution? Droplet precautions for a client who has meningococcal pneumonia An assistive personnel (AP) tells the charge nurse that it is unfair that she has to take care of all the clients who are incontinent. Which of the following responses by the charge nurse is appropriate? "I delegate tasks to personnel based on their job descriptions." A nurse is caring for a client who asks for information about advance directives. Which of the following is an appropriate response by the nurse? "Your advance directives will take effect when you are unable to make health care decisions." A facility has identified an increase in health care-associated urinary tract infections (UTIs) on the medical-surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process? Establish best practice guidelines for reducing the incidence of UTIs. A nurse manager is reviewing the stages of conflict resolution with the nursing staff. The nurse manager should instruct the staff to expect the stages of the conflict to occur in what order? (Order the steps of the process by placing the letters in the correct sequence.) The first stage of the conflict process is latent conflict, which involves awareness of potential situations that can create conflict. Stage two is perceived conflict, where those affected are discussing the situation, but in an impersonal manner. Stage three is felt conflict, where those affected become personally involved. Stage four is manifest conflict, where those involved begin to take action. Stage five is conflict aftermath, where those involved recognize the positive and negative outcomes in how the situation was managed. A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.) The right to be treated with respect and dignity is correct. The code of ethics for nursing requires nurses to treat clients with respect and dignity. The right to full access of the facility is incorrect. Clients only have the right to access common areas of the facility. The right to refuse their medications is correct. Clients have the right to refuse treatment. The right to leave regardless of provider recommendations is correct. Clients have the right to leave the facility against medical advice. The right to be fully informed of their health conditions is correct. It is the nurse‟s responsibility to fully inform clients of their health conditions. A staff nurse detects alcohol on the breath of another nurse working on the unit. He observes that her gait seems unsteady, and she occasionally slurs her speech. Which of the following actions should the nurse take if he suspects that his colleague is under the influence of alcohol? Notify the charge nurse of his assessment. A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A student nurse is photocopying his assigned client's diagnostic test results. An older adult client is being discharged with a postoperative infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge? Ensure that home infusion therapy has been arranged. A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to a licensed practical nurse (LPN)? A client who has Crohn‟s disease and requires an enteral feeding A case manager is initiating the plan of care for a client receiving warfarin who had a stroke. Which of the following is most important for the case manager to include in the client's plan of care? HESI Leadership 7 1. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client‟s need for referral to which of the following providers? a. Speech therapist 2. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasing the clients risk for fall. SATA a. A wheeled office chair at the client‟s computer desk. b. A throw rug covering some cracked vinyl flooring in the kitchen. c. A folding chair without arm rests. 3. A nurse manager is planning to assign care for four clients on a medical-surgical unit. Which of the following clients should the nurse assign to the licensed practical nurse? a. A middle adult client who had a below-the-knee amputation and requires a dressing change. 4. While auditing the medical records of clients currently in the oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advanced directives. Which of the following is the priority action for the nurse to take? a. Ask the nurses who are caring for clients without this medical information to obtain it. 5. A nurse is caring for a group of clients. Which of the following clients should the nurse see first? a. A client who has diabetes mellitus and is diaphoretic. 6. A nurse is receiving change-of-shift report for four clients. Which of the four clients should the nurse care for first? a. A client who is 4 hr. postoperative following a hernia repair and has pitting edema of the right leg. 7. A nurse manager discovers there is a conflict between nurses working the day shift and nurses working the night shift. Which of the following actions should the nurse manager take first? a. Gather information regarding the situation. 8. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Don personal protective equipment. 9. A newly licensed nurse realized that she administered metoprolol 25 mg PO to the wrong client. Which of the following actions should the nurse perform first? a. Measure the client‟s vital signs. 10. A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately? a. Decreased level of consciousness 11. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway? a. A blood culture was obtained after antibiotic therapy had been initiated. 12. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the following clients should the nurse manager assign to a float nurse from the medical- surgical unit? a. A client who is 2 days postoperative following a cesarean birth and is having difficulty ambulating. 13. A nurse is coordinating an interprofessional team to review proposes standards to reduce the transmission of methicillin-resistant Staphylococcus aureas (MRSA). Which of the following members of the interprofessional team should the nurse consult? a. Infection control nurse. 14. A nurse is caring for a client who has uterine prolapse. The provider has recommended to total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take? a. Discuss with the client her concerns with the procedure. 15. A nurse in an emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take? a. Transport the client to the operating room without verifying informed consent. 16. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to an assistive personnel? a. Performing postmortem care prior to transferring the client to the morgue. 17. A nurse working on a quality improvement team that is assessing an increase in client falls at the facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process? a. Identify clients who are at risk for falls. 18. A nurse is completing a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP requires interventions by the nurse? a. The AP uses alcohol hand antiseptic after caring for a client who has Clostridium difficile. 19. A charge nurse that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is priority action by the charge nurse? a. Assess the staff nurses‟ knowledge deficits. 20. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP? a. Collect a urine specimen from a newly admitted client. 21. A nurse is assisting with triage during a mass casualty event. A nurse applies a red tag to a client. Which of the following actions should the nurse take? a. Provide treatment for life-threatening injuries. 22. A home health nurse is performing a safety assessment of a client‟s home. Which of the following findings should the nurse identify as a safety hazard? a. The client‟s bedside lamp is plugged in using an extension cord with two prongs. 23. A charge nurse is observing a newly licensed nurse provide care for a client who has a Clostridium difficile infection. Which of the following actions by the newly licensed nurse indicates an understanding of proper infection control procedure? a. Wears a gown when caring for the client. 24. A nurse is preparing to discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client‟s need for which of the following supplies to manage the tracheostomy at home? (SATA) a. Pipe cleaners b. Obturator c. Oxygen tank 25. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the following clients can give informed consent? a. An adolescent client who is legally emancipated. 26. A nurse is discussing the safe keeping of valuables with a client who is scheduled for surgery. Which of the following client statements indicates the need for further teaching? a. “I can wear my ankle bracelet since I am just having a local anesthetic.” 27. A nurse is caring for an older adult client who has a Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant? a. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation. 28. A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Administers the solution at room temperature. 29. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. “I should encrypt personal health information when sending emails.” 30. A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult when planning for this policy? a. ANA Standards of Practice 31. A charge nurse observes a licensed practical nurse (LPN) tell the client that she will return with a medication to help relieve the client‟s nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ethical principles with the LPN a. Fidelity 32. A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take? a. Use root cause analysis to identify gaps in meeting standards. 33. A nurse enters the 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. 34. A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nurse‟s statements is a proper nurse‟s response? a. “It‟s not too late to cancel the surgery if you want to.” 35. A facility infection control nurse is reviewing the reports of a group of clients. Which of the following infections should the nurse report to the public health department? a. Lyme disease. 36. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? a. The time the client received his last dose of pain medication. 37. A nurse receives a new prescription over the telephone from a client‟s provider. Which of the following actions should the nurse take first? a. Read back the prescription to the provider. 38. A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first? a. Discuss the issue with the A.P 39. A nurse is planning to care for a client who is disoriented and has a history of wandering. Which of the following actions should the nurse include in the plan? a. Provide distractions for the client during the day. 40. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? a. Report the infection to the local health department. 41. A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice? a. Develop a clinical question. 42. A nurse assumes the leading role on the hazardous materials team immediately following a chemical mass casualty incident in the community. As clients arrive at the designated triage area outside the hospital, which of the following actions should the nurse take? a. Remove contaminated clothing. 43. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Libel 44. A nurse is preparing to complete morning assessments on several assigned clients. Which of the following clients should the nurse assess first? a. A client who has a nasogastric tube to intermittent suction and reports nausea. 45. A charge nurse overhears a staff nurse discussing a client‟s diagnosis in the cafeteria. Which of the following responses should the charge nurse make? a. “Please stop discussing the client in a public area.” 46. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique? a. Uses sterile forceps to pack sterile gauze into the wound. 47. A nurse working in a long-term care facility is assessing an older adult client who has been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the following actions should the nurse take? a. Clean the equipment in the client‟s room with bleach. 48. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for the assigned clients. Which of the following interventions is appropriate? a. Recommend that he take time to plan at the beginning of his shift. 49. A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports the referral? a. The client needs to arrange financial resources to purchase equipment. 50. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid arthritis. Which of the following assessment findings supports the need for a referral? a. The client requires assistance with completing oral hygiene. 51. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regards to this client‟s care? SATA a. Mental health counselor b. Case manager c. Nutritional therapist 52. A nurse is prioritizing care after receiving a change-of-shift report on four clients. Which of the following clients should the nurse assess first? a. A client who reports indigestion and jaw pain. 53. A nurse on an acute mental health unit is assessing four clients. Which of the following clients is highest priority? a. A client who has bipolar disorder and displays constant pacing. 54. A nurse is planning care for a group of clients. Which of the following actions should the nurse take first? a. Check a client who has a leg cast and reports a new onset of pain. 55. A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a healthcare proxy. Which of the following responses should the nurse make? a. “A healthcare proxy can make decisions for you when you are unable to do so.” 56. A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two medications stating, “I‟ve never taken these before.” Which of the following actions should the nurse take first? a. Compare the client‟s medication administration record with the prescriptions on the transfer orders. 57. A nurse on a medical surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who is postoperative following a laminectomy 12 hr. ago and is unable to void. 58. A nurse in an emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take? a. Prepare to administer antibiotics to the client. 59. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? a. Determine the reasons the nurses are not taking their scheduled breaks. 60. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following? a. Battery 61. A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit. Which of the following responses by the nurse is appropriate? a. “Please ask your relative about this, because I cannot share this information about her.” HESI Leadership/Management 1. Accountability the ability and willingness to assume responsibility for actions and related consequences. 2. Assault Mental or physical threat (e.g., forcing [without touching] a client to take a medication or treatment) 3. Authority the right to act or command the actions of others 4. Battery touching, with or without the intent to do harm (e.g., hitting or striking a client). If a mentally competent adult is forced to have a treatment he or she has refused, battery occurs. 5. Biologic agents A. Anthrax. B. Pneumonic plague. C. Botulism. D. Smallpox. E. Inhalation tularemia. F. Viral hemorrhagic fever 6. Bioterrorism A. Learn the symptoms of illnesses that are associated with exposure to likely biologic and chemical agents. B. Understand that they could appear days or weeks after exposure. C. Nurses and other HCPs would be the first responders when victims seek medical evaluation after symptoms manifest. First responders are critical in identifying an outbreak, determining cause of outbreak, identifying risk factors, and implementing measures to control and minimize the outbreak. 7. Breach of duty failure to perform according to the established standard of conduct in providing nursing care 8. By what authority may RNs delegate nursing care to others? State Nurse Practice Act 9. Case management: 1. Coordination of care provided by an interdisciplinary team. 2. Manages resources effectively. 3. Uses critical pathways to organize care 10. Causation a connection exists between conduct and the resulting injury referred to as "proximate cause" or "remoteness of damage" 11. Chemical agents A. Biotoxin agents: ricin. B. Nerver agents: sarin 12. Civil procedures methods used to protect the rights of psychiatric clients 13. Collaborative health care teams require; 1. Shared goals, commitment, and accountability. 2. Open and clear communication. 3. Respect for the expertise of all team members. 14. Commission of a crime involves... 1. A person commits a deed contrary to criminal law. 2. A person omits an act when there is a legal obligation to perform such an act (e.g., refusing to assist with the birth of a child if such a refusal results in injury to the child). 3. Criminal conspiracy occurs when two or more persons agree to commit a crime. 4. Assisting or giving aid to a person in the commission of a crime makes that person equally guilty of the offense (awareness must be present that the crime is being committed). 5. Ignoring a law is not usually an adequate defense against the commission of a crime (e.g., a nurse who sees another nurse taking narcotics from the unit supply and ignores this observation is not adequately defended against committing a crime). 6. Assault is justified for self-defense. However, to be justified, only enough force can be used as to maintain self- protection. 7. Search warrants are required prior to searching a person's property. 8. It is a crime not to report suspected child abuse (i.e., the nurse's legal responsibility is to report suspected child abuse) 15. Communication Skills Assertive communication: A. Includes clearly defined goals and expectations. B. Includes verbal and nonverbal messages that are congruent. C. Is critical to the directing aspect of management. 16. Competency hearing Legal hearing that is held to determine a person's ability to make responsible decisions about self, dependents, or property. 1. Persons declared incompetent have the legal status of a minor--they cannot: vote, make contracts or wills, drive a car, sue or be sued, hold a professional license. 2. A guardian is appointed by the court for an incompetent person. Declaring a person incompetent can be initiated by the state or the family. 17. Consent The law does not require written consent to perform medical treatment. 1. Treatment can be performed if the client has been fully informed about the procedure. 2. Treatment can be performed if the client voluntarily consents to the procedure. 3. If informed consent cannot be obtained (e.g., client is unconscious) and immediate treatment is required to save life or limb, the emergency laws can be applied 18. Consent of minors 1. Minors 14 years of age and older must agree to treatment along with their parents or guardians. 2. Emancipated minors can consent to treatment themselves. Be aware that the definition of an emancipated minor may change from state to state. 19. Crime An act contrary to a criminal statute. Wrongs punishable by the state, committed against the state, with intent usually present. The nurse remains bound by all criminal laws. 20. Critically thinking model 1. Assessment: What are the needs or problems? 2. Analysis: What has the highest priority? 3. Planning: What outcomes and goals must be accomplished? What are the available resources? (1) Nursing staff (2) Interdisciplinary team members (3) Time (4) Equipment (5) Space (client rooms, home environment, etc.). 4. Implementation: Communication expectations. Is documentation complete? 5. Evaluation: Were the desired outcomes achieved? Was safe, effective care provided? 21. Critical pathways: 1. Are interdisciplinary plans of care. 2. Are used for diagnoses and care that can be standardized. 3. Are guides to track client profess. 4. Do not replace individualized care 22. Critical Thinking Skills Nurses are accustomed to using the nursing process as the model for problem-solving in client care situations. 23. Defamation divulgence of privileged information or communication (e.g., through charts, conversations, or observations) 24. Define an intentional tort, and give one example Conduct causing damage to another person in a willful or intentional way without just cause. Example: Hitting a client out of anger, not in a manner of self-protection 25. Define triage To sort or categorize 26. Delegation the process by which responsibility and authority are transferred to another individual 27. Delegation skills The authority, accountability, and responsibility of the RN are based on the state Nurse Practice Act, standards of professional practice, the policies of the health care organization, and ethical-legal models of behavior. The nurse transfers responsibility and authority for the completion of delegated tasks, but the nurse retains accountability for the delegation process. This accountability involves ensuring that the five rights of delegation have been achieved 28. Describe 6 patient rights guaranteed under HIPAA A patient must give written consent before HCPs can use or disclose personal health regulations that nurses must be aware of in practice information; HCPs must give patients notice about providers' responsibilities regarding patient confidentiality; patients must have access to their medical records; providers who restrict access must explain why and must offer patients a description of the complaint process; patients have the right to request that changes be made in their medical records to correct inaccuracies; HCPs must follow specific tracking procedures for any disclosures made that ensure accountability for maintenance of patient confidentiality; patients have the right to request that HCPs restrict the use and disclosure of their personal health information, though the provider may decline to do so. 29. Describe nursing care of the restrained client Apply restraints properly; check restraints frequently to see that they are not causing injury and record such monitoring; remove restraints as soon as possible; use restraints only as a last resort. 30. Describe the nurse's legal responsibility when asked to perform a task for which he or she is unprepared. Inform the HCP or person asking the nurse to perform the task that he or she is unprepared to carry out the task; refuse to perform the task. 31. Differentiate between voluntary and involuntary admission Voluntary: Client admits self to an institution for treatment and retains his or her civil rights; he or she may leave at any time. Involuntary: Someone other than client applies for the client's admission to an institution (a relative, a friend, or the state); requires certification by one or two HCPs that the person is a danger to self or others; the person has a right to a legal hearing (habeas corpus) to try to be released, and the court determines the justification for holding the person. 32. Direction/guidance 1. Clear, concise directions. 2. Expected outcome. 3. Time frame. 4. Limitations. 5. Verification of assignment 33. Duty Obligation to use due care (what a reasonable, prudent nurse would do); failure to care for and/or to protect others against unreasonable risk. The nurse must anticipate foreseeable risks. Example: If a floor has water on it, the nurse is responsible for anticipating the risk for a client's falling. 34. Emergency admission Any adult may apply for emergency detention of another. However, medical or judicial approval is required to detain anyone beyond 24 hours. 1. A person held against his or her will can file a writ of habeas corpus to try to get the court to hear the case and release the person. 2. The court determines the sanity and alleged unlawful restraint of a person. 35. Emergency Care A. Good Samaritan Act. B. A nurse is required to perform in a "reasonable and prudent manner" 36. Evaluation/monitoring 1. Frequent check-in. 2. Open communication lines. 3. Achievement of outcome 37. Examples of negligence or malpractice 1. Burning a client with a heating pad. 2. Leaving sponges or instruments in a client's body after surgery. 3. Performing incompetent assessments. 4. Failing to heed warning signs of shock or impending MI. 5. Ignoring signs and symptoms of bleeding. 6. Forgetting to give a med or giving the wrong med 38. Exposure of a person Exposure or discussion of a client's case. After death, a client has the right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body. 39. False imprisonment confinement without authorization 40. Five Rights of Delegation 1. Right task: Is this a task that can be delegated by a nurse? 2. Right circumstance: Considering the setting and available resources, should delegation take place? 3. Right person: Is the task being delegate by the right person to the right person? 4. Right direction/communication: Is the nurse providing a clear, concise description of the task, including limits and expectations? 5. Right supervision: Once the task has been delegate, is appropriate supervision maintained/ 41. Follow-up 1. Communication of evaluation findings to the LPN or UAP and other appropriate personnel. 2. Need for teaching or guidance. 42. Four elements necessary to prove negligence or malpractice duty, breach of duty, injury/damages, causation 43. Fraud willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Examples of fraud include: 1. Presenting false credential for the purpose of entering nursing school, obtaining a license, or obtaining employment. 2. Describing a myth regarding a treatment (e.g., telling a client that a placebo has not side effects and will cure the disease or telling a client that a treatment or diagnostic test will not hurt, when indeed pain is involved in the procedure) 44. Good Samaritan Act Protects health practitioners against malpractice claims for care provided in emergency situations (e.g., the nurse gives aid at the scene to an automobile accident victim) 45. Health Insurance Portability and Accountability Act of 1996 A. HIPAA privacy rules pertain to health care providers, health plans, and health clearinghouses and their business partners who engage in computer-to-computer transmission of health care claims, payment and remittance, benefit information, and health plan eligibility information and who disclose personal health information that specifically identifies an individual and is transmitted electronically, in writing, or verbally. B. Patient privacy rights are of key importance. Patients must provide written approval of the disclosure of any of their health information for almost any purpose. HCP must offer specific information to patients that explains how their personal health information will be used. Patients must have access to their medical records, and they can receive copies of them and request that changes be made if they identify inaccuracies. C. HCPs who do not comply with HIPAA regulations or make unauthorized disclosures risk civil and criminal liability. 46. HESI Hint#1 Surgical procedures should be explained by the health care provider. Remember that it is the nurse's responsibility to be sure that the operative permit is signed and is on the chart. It is not the nurse's responsibility to explain the procedure to the client. 47. HESI Hint #2 Often questions are asked regarding the Good Samaritan Act, which is the means of protecting a nurse when she or he is performing emergency care. 48. HESI Hint #3 If the nurse carries out a HCP's prescription for which he or she is not prepared and does not inform the HCP of his or her lack of preparation, the nurse is solely liable for any damages. If the nurse informs the HCP of his or her lack of preparation in carrying out a prescription and carries out the prescription anyway, the nurse and the HCP are liable for any damages 49. HESI Hint #4 Assignments are often tested on the NCLEX-RN. The Nurse Practice Acts of each state govern policies related to making assignments. Usually, when determining who should be assigned to do a sterile dressing change, for example, a licensed nurse should be chosen--and RN or LPN who has been checked off on this procedure. 50. HESI Hint#5 Assertive communication starts with "I need" rather than with "You must" 51. HESI Hint #5 Restraints of any kind may constitute false imprisonment. Freedom from unlawful restraint is a basic human right and is protected by law. 52. HESI Hint #6 Motivation comes from within an individual. A nurse leader can provide an environment that will promote motivation through positive feedback, respect, and seeking input. Look for responses that demonstrate these behaviors. 53. HESI Hint #7 NCLEX questions often include examples of nursing interventions that do or do not demonstrate these skills and characteristics 54. HESI Hint #8 Effective leadership involves assertive management skills. Look for responses that demonstrate that the nurse is using assertive communication skills 55. HESI Hint #9 Delegating to the right person requires that the nurse be aware of the qualifications of the delegatee: Appropriate education, training, skills, experience, and demonstrated and documented competence. 56. HESI Hint #10 UAPs generally do not perform invasive or sterile procedures 57. HESI Hint #11 The RN is accountable for adhering to the 3 basic aspects of supervision when delegation to other health care personnel, such as LPNs, graduate nurses, inexperienced nurses, student nurses, and UAPs. 58. HESI Hint #12 Remember the nursing process: Assessments, analysis, diagnosis, planning, and evaluation (any activity requiring nursing judgment) may not be delegated to UAP. Delegated activities fall within the implementation phase of the nursing process. 59. HESI Hint #13 Priorities often center on which client should be assessed first by the nurse. Ask yourself: Which client is the most critically ill? Which client is most likely to experience a significant change in condition? Which client requires assessment by an RN? 60. HESI Hint #14 The nurse manager must analyze all the desired outcomes involved when assigning rooms for clients or assigning client care responsibilities. A client with an infection should not be assigned to share a room with a surgical or immunocompromised client. A nurse's client care management should be based on the nurse;s abilities, the individual client's needs, and the needs of the entire group of assigned clients. Safety and infection control are high priorities 61. HESI Hint #15 Change causes anxiety. An effective nurse change agent uses problem-solving skills to recognize factors such as anxiety that contribute to resistance to change and uses decision-making and interpersonal skills to overcome that resistance. Interventions that demonstrate these skills include seeking input, showing respect, valuing opinions, and building trust. 62. HESI Hint #16 It is important to remember that in disaster and bioterrorism management, the nurse must consider both the individual and the community. 63. Hospital policies provide a guide for nursing actions. They are not laws, but courts generally rule against nurses who have violated the employer's policies. Hospital can be liable for poorly formulated or poorly implemented policies 64. Identify three bioterrorism agents Anthrax, pneumonic plague, botulism, smallpox, inhalation tularemia, viral hemorrhagic fever, ricin, sarin, radiation. 65. If a nurse is asked to perform a task for which he or she has not been prepared educationally or does not have the necessary experience: 1. Inform the HCP that he or she does not have the education or experience necessary to carry out the prescription. 2. Refuse to carry out the prescription 66. If a nurse questions a HCP's prescription because he or she believes that it is wrong: 1. Inform the HCP. 2. Record that the HCP was informed and record the HCP's response to such information. 3. Inform the nursing supervisor. 4. Refuse to carry out the prescription. 67. If the nurse believes that a HCP's prescription was made with poor judgment: 1. Record that the HCP was notified and that the prescription was questions. 2. Carry out the prescription because nursing judgment cannot be substituted for a HCP's judgment. 68. Inability to stand trial person accused of committing a crime is not mentally capable of standing trial. He or she: 1. Cannot understand the charge against himself or herself. 2. Must be sent to psychiatric unit until legally determined to be competent for trial. 3. Once mentally fit, must stand trial and serve any sentence, if convicted 69. Incident reports alert administration to possible liability claims and the need for investigation; they do not protect against legal action being taken for negligence or malpractice 70. Informed consent operation has been fully explained to the client including: 1. Possible complications and disfigurements 2. Removal of any organs or parts of the body. 71. Injury/damages failure to meet standard of care, which causes actual injury or damage to the client, either physical or mental. 72. Insanity legal term meaning the accused is not criminally responsible for the unlawful act committed because he or she is mentally ill. 73. Intentional Torts Assault and battery, Invasion of privacy, False imprisonment, Exposure of a person, Defamation, Fraud 74. Invasion of privacy Encroachment or trespassing on another's body or personality 75. involuntary admission someone other than the client applies for the client's admission to an institution. 1. This requires certification by a health care provider that the person is a danger to self or others (Depending on the state, one or two health care provider certifications are required). 2. Individuals have the right to a legal hearing within a certain number of hours or days. 3. Most states limit commitment to 90 days. 4. Extended commitment is usually no longer than 1 year. 76. Laws Governing Nursing Nurse Practice Acts 77. Leadership and Management Nurses act in both leadership and management roles. A. A leader is an individual who influences people to accomplish goals. B. A manager is an individual who works to accomplish the goals of the organization. C. A nurse manager acts to achieve the goals of safe, effective client care within the overall goals of a health care facility. 78. Leadership styles and behaviors associated Democratic (participative)--Assertive. Authoritarian (autocratic)--Aggressive. Laissez- faire (permissive)--Passive. 79. Legal and civil rights of hospitalized clients 1. The right to wear their own clothes and to keep personal items and a reasonable amount of cash for small purchases. 2. The right to have individual storage space for one's own use. 3. The right to see visitors daily. 4. The right to have reasonable access to a telephone and the opportunity to have private conversations by telephone. 5. The right to receive and send mail (unopened). 6. The right to refuse shock treatments and lobotomy. 80. List examples of the three levels of prevention in disaster management Primary: Develop plan, train and educate personnel and public. Secondary: Triage, treatment-shelter supervision. Tertiary: Follow- up, recovery assistance, prevention of future disasters. 81. List five activities a person who is declared incompetent cannot perform vote, make contracts or wills, drive a car, sue or be sued, hold a professional license. 82. List the four elements that are necessary to prove negligence Duty. Breach of duty. Causation. Damages 83. List the three levels of disaster management Disaster preparedness, disaster response, disaster recovery. 84. Malpractice negligence by professional personnel (e.g., professional misconduct or unreasonable lack of skill in carrying out professional duties) 85. Mandatory Nurse Practice Acts authorize that, under the law, only licensed professionals an practice nursing. 86. Name three legal requirements of a surgical permit voluntary, informed, written 87. Negligence performing an act that a reasonable and prudent person would not perform. The measure of negligence is "reasonableness" (i.e., would a reasonable and prudent nurse act in the same manner under the same circumstances?) 88. Negligence is measured by reasonableness. What question might the nurse ask when determining such reasonableness? Would a reasonable and prudent nurse act in the same manner under the same circumstances? 89. The nurse cannot, without a HCP's prescription: alter the amount of drug given to a client. For example, if a HCP has prescribed pain medication in a certain amount and the client's pain is not, in the nurse's judgment, severe enough to warrant the dosage prescribed, the nurse cannot reduce the amount without first checking with the HCP. Remember nursing judgment cannot be substituted for medical judgment. 90. Nurse Leaders and Managers as Change Agents Unfreezing--Initiation of a change. Moving-- Motivation toward a change. Refreezing-- Implementation of a change 91. Nurse Practice Acts provide the laws that control the practice of nursing in each state. 92. Nurse's Responsibility in making assignments governed by Nurse Practice Acts. 1. Assignments should be commensurate with the nursing personnel's educational preparation, experience, and knowledge. 2. The nurse should supervise the care provided by nursing personnel for which he or she is administratively responsible. 3. Sterile or invasive procedures should be assigned to or supervised by a professional nurse (RN). 93. Nursing Assessment Disaster A. Community-disaster risk assessment. B. Measures to mitigate disaster effect. C. Exposure symptom identification. 94. Nursing Interventions and Roles in Triage A. Triage duties using a systematic approach such as the START method. B. Treatment of injuries. 1. Render first aid for injuries. 2. Provide additional treatment as needed in definitive care areas. C. Treatment of other conditions, including mental health. 1. Determine health needs other than injury. 2. Refer for medical treatment as required. 3. Provide treatment for other conditions based on medically approved protocols. 95. Nursing Plans and Interventions Disasters A. Participate in development of disaster plan. B. Educate the public on disaster plan and personal preparation for disaster. C. Train rescue workers in triage and basic first aid. D. Educate personnel for shelter management. E. Practice triage. F. Treat injuries and illness. G. Treat other conditions, including mental health. H. Supervise shelters. I. Arrange for follow-up care for injuries. J. Arrange for follow-up care for psychological problems. K. Assist in recovery. L. Work to prevent future disasters and their consequences. 96. Nursing responsibilities with regard to restraints 1. The nurse must notify the HCP immediately that the client has been restrained. 2. The nurse should document the facts regarding the rationale for restraining the client. 97. Organizational Skills encompass management of: A. people. B. time. C. supplies 98. Patient Identification A. The Joint Commission has implemented new patient identification requirements to meet safety goals. B. Use at least two patient identifies whenever taking blood samples, administering meds, or administering blood products. C. The patient room number may not be used as a form of identification. 99. Possible agents. Biologic agents. Chemical agents. Radiation. 100. Prescriptions and HCPs A nurse is required to obtain a prescription (order) to carry out medical procedures from a HCP. 101. Primary prevention in Disaster Management 1. Participate in the development of a disaster plan. 2. Train rescue workers in triage and basic first aid. 3. Educate personnel about shelter management. 4. Educate the public about the disaster plan and personal preparation for disaster 102. Psychiatric Nursing Practice and the Law Civil procedures, Voluntary admission, Involuntary admission, Emergency admission, Legal and civil rights of hospitalized clients, competency hearing, insanity, inability to stand trial. 103. Quality assurance: 1. Involves continuous quality improvement (CQI)/total quality management (TQM). 2. Is an organized approach to the improvement of: Outcome achievement, Quality of care provided. 104. Responsibility the obligation to complete a task 105. Restraints Clients may be restrained only under the following circumstances: 1. in an emergency. 2. for a limited time. 3. for the purpose of protecting the client from injury or from harm 106. The role of the nurse takes place at all three levels of disaster management: 1. Disaster preparedness. 2. Disaster response. 3. Disaster recovery 107. Secondary prevention in Disaster Management 1. Triage. 2. Treatment of injuries. 3. Treatment of other conditions, including mental health. 4. Shelter supervision. 108. Shelter Supervision A. Coordinate activities of shelter workers. B. Oversee records of victims admitted and discharged from shelter. C. Promote effective interpersonal and group interactions among victims in shelter. D. Promote independence and involvement of victims housed in the shelter. 109. Simple triage and rapid treatment (START) Assess Respirations. Assess Circulation. Assess Mental Status 110. Skills Needed by Change Agents A. Problem-solving B. Decision-making C. Interpersonal relationships 111. Skills of the Nurse Communication, Act as a liaison between clients Manager and others, Engage in conflict resolution as needed with staff. Organization, Plan overall strategies to address client problems, Review management outcomes. Delegation, Identify roles/responsibilities of health care team members. Supervision, Supervise care provided by others. Critical thinking, Serve as resource person to other staff 112. Supervision Skills Direction/guidance. Evaluation/monitoring. Follow-up. 113. Surgery permits must be obtained as follows 1. They must be witnessed by an authorized person, such as the HCP or a nurse. 2. They protect the client against unsanctioned surgery, and they protect the HCP and surgeon, hospital, and hospital staff against possible claims of unauthorized operations. 3. Adults and emancipated minors may sign their own operative permits if they are mentally competent. 4. Permission to operate on a minor child or an incompetent or unconscious adult must be obtained from a legally responsible family member or guardian. 114. Surgical Permit Consent to operate (surgical permit) must be obtained prior to any surgical procedure, however minor it might be. Must be 1. written. 2. obtained voluntarily. 3. explained to the client (i.e., informed consent must be obtained). 115. Tertiary prevention in Disaster Management 1. Follow-up care for injuries. 2. Follow-up care for psychological problems. 3. Recovery assistance. 4. Prevention of future disasters and their consequences 116. To achieve effective disaster management: 1. Organization is the key. 2. All personnel must be trained. 3. All personnel must know their roles. 117. Torts An act involving injury or damage to another (except breach of contract) resulting in civil liability (i.e., the victim can sue) instead of criminal liability 118. Triage A French word meaning "to sort or categorize." Goal: Maximize the number of survivors by sorting the injured according to treatable and untreatable victims. Primary criteria used: Potential for survival, Availability of resources. 119. Triage Color Code System Red--Most urgent, first priority. Life-threatening injuries. No delay in treatment. Yellow--Urgent, second priority. Injuries with systemic effects and complications. May delay treatment for 30- 60 min. Green--Third priority. Minimal injuries with no systemic complications. Several hours. Black--Dying or dead. Catastrophic injuries. No hope for survival, no treatment 120. A UAP may perform care that falls within which component of the nursing process? Implementation 121. Unintentional Torts Negligence and malpractice 122. Verbal consent a notation should be made. 1. It describes in detail how and why verbal consent was obtained. 2. It is placed in the client's record or chart. 3. It is witnessed and signed by two persons. 123. Verbal or written consent can by given by: a. Alert, coherent, or otherwise competent adults. b. A parent or legal guardian. c. A person in loco parentis (a person standing in for a parent with a parent's rights, duties, and responsibilities) in cases of minors or incompetent adults. 124. Verbal telephone prescriptions should be avoided, the nurse should follow the agency's policy and procedures. Failure to follow such rules could be considered negligence. The Joint Commission requires that organizations implement a process for taking verbal or telephone orders that includes a read-back of critical values. The employee receiving the prescription should write the verbal order or critical value on the chart or record it in the computer and then read back the order or value to the HCP. 125. Voluntary admission client admits himself or herself to an institution for treatment and retains civil rights 126. What actions should the nurse take if he or she questions a HCP's prescription--that is, believes the prescription is wrong? Inform the HCP; record that the HCP was informed and the HCP's response to such information; inform the nursing supervisor; refuse to carry out the prescription. 127. What are the essential steps of effective supervision? direction, evaluation, and follow-up 128. What are the five rights of delegation? Right task, right circumstance, right person, right direction or communication, and right supervision. 129. What law protects the nurse who provides care or gives aid in an emergency situation? The Good Samaritan Act 130. What types of procedures should be assigned to professional nurses? Sterile or invasive procedures 131. When restraining a client, the nurse should do the following: 1. Use restraints (physical or chemical) after exhausting all reasonable alternatives. 2. Apply the restraints correctly and in accordance with facility procedures. 3. Check frequently to see that the restraints do not impair circulation or cause pressure sores or other injuries. 4. Allow for nutrition, hydration, and stimulation at frequent intervals. 5. Remove restraints as soon as possible. 6. Document the need for and application, monitoring, and removal of restraints. 132. Which of the following is an example of assertive communication? A. "You need to improve the way you spend your A. Aggressive communication, which causes anger, hostility, and defensive attitude. B. Assertive communication begins with "I" rather than "you" and time so that all of your care gets performed." B. "I've noticed that many of your clients did not get their care today." clearly states the problem. 133. Which tasks can be delegated to a UAP? A. Inserting a Foley catheter. B. Measuring and recording the client's output through a Foley catheter.C. Teaching a client how to care for a catheter after discharge. D. Assessing for symptoms of a UTI A. Is a sterile invasive procedure and should not be delegated to a UAP. B. Falls within the implementation phase of the nursing process and dose not require nursing judgment. Evaluation of the I&O must be done by the nurse. C. Client teaching requires the abilities of a nurse and should not be delegated. The UAP may be instructed to report anything unusual that is observed and any symptoms reported by the client, but this does not replace assessment by the nurse. D. Assessment must be performed by the nurse and should not be delegated. The UAP may be instructed to report anything unusual that is observed, or any symptoms reported by the client, but this does not replace assessment by the nurse 134. Which type of communication is necessary to implement a democratic leadership style? Assertive communication skills 135. Who may give consent for medical treatment? alert, coherent, or otherwise competent adults; a parent or legal guardian; a person in loco parentis of minors or incompetent adults HESI Leadership/Management 1. #1 thing to remember about negative feedback Unsatisfactory work must be acknowledged and discussed 2. 2 biggest/worst actions that lead to malpractice lawsuits Altering/falsifying a medical record, violation of an internal or external standard of practice 3. 2 out of 3 people leave a job because of this Ineffective/incompetent management 4. 2 types of change Planned/Managed, Unplanned/Reactive 5. 2 types of resistance to change Active resistance and passive resistance 6. 2 ways to be an emotionally stable leader 1. Recognize and understand your own emotions, learn to manage them, stay calm and clear headed. 2. Listen to others, perceive unspoken concerns, acknowledge others perspectives, helpful 7. 3 qualifications for RN licensure in the USA Graduate from an approved RN program, english language proficiency, disclosure of criminal convictions 8. 3 quality behaviors of effective nurse managers? Interpersonal, decisional and informational behaviors along with leadership, business sense and clinical expertise 9. 3 stages of lewins theory of change Unfreeze(take out of comfort zone), Change(discomfort), Refreeze(new comfort zone) 10. 3 types of liability Personal, vicarious, employer/corporate 11. 4 stages of burnout 1. high expectations and idealism, 2. pessimism and early job dissatisfaction, 3. withdrawal and isolation 4. irreversible detachment and loss of interest 12. According to JCAHO what is the reason for a large number of sentinel events that occur? Communication deficits among health care providers 13. According to Rogers what are typical innovators, early adapters, early majority, late majority, laggards and rejectors. responses to change? 14. Advice for giving feedback Give both negative and positive, give immediately, give frequently, give negative feedback in private, base it on observed behavior, include suggestions for change. 15. AKA - Bottling emotions (inappropriate way of dealing reality shock) Rutter 16. These are activities that an RN may NOT delegate Initial and follow up assessments, decisions and judgements about client plan of care, interventions that require professional RN knowledge or skills, decisions/judgements needed to evaluate care 17. These are clinical protocols involving all disciplines Critical pathways 18. These are established guidelines for the nursing profession to ensure quality of care Nursing Standards 19. are influenced by values Choices 20. These are non life essential values (things, people, ideas, kindness, and understanding) Extrinsic values 21. These are offenses committed against state laws Criminal acts 22. These are organized thoughts about why people exist in the universe Beliefs 23. Behaviors at risk for violence History of violent behavior, delusions paranoia suspicion, aggression, threats, rapid speech, anger, stiff posture, clenched fists, ETOH/drug use, male or youth, unrealistic policies/procedures 24. Causes of reality shock Culture shock (expectations distorted with reality), incongruent school values and work values, lack of support, lack of a mentor 25. Choices to resolve conflict Avoid it, accommodate, compete, compromise, collaborate 26. Common actions leading to malpractice lawsuits Fail to assess properly, fail to report changes in pt status, fail to document, fail to obtain informed consent, fail to report co-worker negligence, fail to provide adequate education * TWO BIGGEST* Altering/falsifying a medical record and Violation of an internal or external standard of practice 27. Common causes of negligence Client falls, equipment injuries, failure to monitor, failure to communicate, medication errors, medical errors 28. Common mistakes made during change implementation Failure to make need for change clear, unclear goals, too little time, poor leadership, insufficient coordination of the change process, insufficient education, dismissing complaints 29. The CQI program evaluates what 3 things? 1.Structure within which care is given, 2. the process of giving the care 3. the outcome of that care 30. Describe the traditional organizational structure Tall and narrow chain of command - Employees ranked top to bottom with the number on bottom greater than the top, authority is at the top only, power is distributed, communication is a challenge because of all of the layers of power 31. Dont's of feedback Focus on negatives, let personalities intrude, be vague, play favorites, correct people publicly 32. Do's and Don'ts for managing diversity Do - recognize it, value it and develop support for it, Ensure fairness, make all of the above part of your philosophy. Don't- pretend all are alike, expect everyone to conform, seek quick solutions, develop different performance standards, expect one workshop/meeting to solve it. 33. Do's of feedback Include positive comments, be objective, be specific, treat everyone the same, correct people privately 34. These ethical concepts are learned and change with maturity and experience Values (The amount of values a person holds, isn't as important as "which" values they consider important) 35. Explain the differences between management and leadership Management-Assigned formal position, budgets, hires/fires. Leadership -Achieved informal position, part of every RN's responsibility 36. Formal statements of behavior rules for a group Ethical Codes 37. Goals of managed healthcare organizations Decrease cost, promote health, provide seamless healthcare 38. Good empowers others Leadership 39. How are error events in health care categorized? Near miss, adverse event, accident, never event 40. How do managed health care organizations control costs? By providing incentives to consider lower cost treatment alternatives 41. How do managed healthcare organizations promote health? Education, early diagnosis, self-care, prevention, reduce duplication 42. How do nurses practice autonomy for pts? Respecting the pts right to make their own choices about healthcare 43. How do nurses practice beneficence for pt care? They need to assist pts in meeting all of their needs (Biological, psychological, social) 44. How do nurses practice nonmaleficence for their pts? Requires nurse to protect pts who can not protect themselves 45. How do nurses treat pts with justice? They must be nonjudgmental to every patient 46. How is the nursing process used while delegating care? Use Assessment to assess needs of pts, set specific goals, match the right personnel with the appropriate skills care for the pt, Use Planning to mentally identify who is best suited for the task, and prevent later problems, Use implementation to assign appropriate personnel who have the right level of expertise for the pt to deliver the care, and use Evaluation to oversee the care and determine if the pt care needs have been met and allow for feedback. 47. How much actual time does an RN spend on pt care? 35% 48. How to prepare for a trial deposition Don't volunteer information, be familiar with the case, clarify questions, don't assume, don't exaggerate, allow 5 seconds before answering (Practice this), tell the truth always, speak slow and clear, eye contact, bring resume, request a break/rest, think before answering, avoid anger/absolutes, read deposition ahead of time, if asked the same question twice- ask them to play back or repeat your previous answer. 49. Inappropriate reactions when dealing with reality shock Native (i'll just keep doing this because it's easier), runaway, rutter, burnout, loner, remain new, be the change agent 50. In this nursing care delivery model the nurse is responsible for planning, organizing, and delivering all care. It is the oldest method of organizing care. Total Patient Care Nursing 51. In this nursing care delivery model the RN acts as a leader and coordinates all care for a group of patients. Was formed in the 50's to improve pt satisfaction and reduce fragmented care Team Nursing (RN team A LPN team A PCA team A delivers care for the group of pts assigned to team A; RN teamb, LPN team B PCA team B delivers care for the group of pts assigned to team B) 52. In this nursing care delivery model, the RN is the main caregiver and responsible for planning, directing and evaluating all care. Created in the 70's for promoting RN autonomy. Primary Nursing 53. In this nursing care delivery model the staff members are assigned to complete tasks for a specific group of patients and unskilled workers are trained to perform routine simple tasks, evolved during WWII as a result of the nursing shortage. Functional Nursing 54. In this type of managed health care organization, the primary care provider controls access to services HMO 55. In this type of organization, authority figures have all of the power/control Centralized/Traditional 56. Is burnout an emotional disturbance or a reaction to organizational stressors? It is a reaction to organizational stressors 57. Keys to surviving reality shock Think before you answer, take vacations, support co-workers (be a good listener), be comfortable, treat yourself, get rid of energy drains, learn to say NO 58. Laws relevant to Nursing Good samaritan, confidentiality, slander/libel, false imprisonment, assault and battery, malpractice, liability, and negligence 59. List 3 levels of criminal law offenses Felony, Misdemeanor, Juvenile 60. List 3 qualities a leader must develop 1. Ability to diagnose or understand the situation you want to influence or change 2. Adaptation in order to allow your behaviors to close the gap between the current situation and what needs to be changed 3. Communication 61. List 3 sources that laws come from Constitution, statutes, Administrative 62. List 3 types of healthcare -Private/nonprofit, publicly supported, organizations private/for profit 63. List 4 points about grapevine communication It always exists, it travels rapidly, spontaneous, may lack accuracy 64. List four types of nursing care delivery methods Team nursing, Functional nursing, Primary nursing, total care nursing 65. List some barriers to effective delegation lack of experience, lack of licensure, quality of care, assigning work to others, poor communication or follow through/follow up, lack of trust 66. List some behaviors characteristic of a leaders Critical thinking, problem solving, respect people, communicates skillfully, sets goals, shares a vision, develops self and others 67. List some examples of professional negligence Duty owed, duty breached, forseeability(Knowingly fails to meet standards), causation, injury, damages 68. List some sources of power Formal vs informal, authority, reward, coercion, expertise/information, connections/referent 69. List some ways RNs organize their work Set long and short term goals, use lists, ticker files, time blocks, filing systems 70. list the 4 phases of unplanned change? Design the change, plan implementation, implement the change, integrate the change 71. List the 5 dimensions of followership Courage to assume leadership/responsibility as needed, courage to serve, courage to challenge, courage to participate in change/transformation, courage to leave 72. List the conflict resolution process Identify the problem, generate possible solutions, evaluate suggested solutions, choose the best solutions, implement the solution chosen, is the problem solved?, if yes end process if not repeat. 73. Major issues handled by the state boards of nursing include what? Falsifying documents, felonies, drugs/alcohol problems, functioning outside the scope of practice, abuse 74. The manager that believes this theory of McGregor believes in guidance rather than control and development rather than supervision with added rewards is the best way to manage employees Theory Y 75. The manager that believes this theory of McGregor believes that employees need strict rules, constant supervision and threat of punishment Theory X 76. McGregor has two theories of workers name them Theory X and Theory Y 77. Name 3 types of managed healthcare HMO, PPO, POS 78. Name four types of costs incurred by businesses Direct, indirect, fixed and variable 79. Name some ethical principles Autonomy, nonmaleficence, beneficence, justice, fidelity, confidentiality, veracity, accountablity 80. Name some types of Standards nurses must follow Internal, organizational, accepted state and national standards, nurse practice acts, patient care partnerships 81. Name some ways that healthcare is financed Insurance companies, Government insurance, managed care organizations 82. Name the ethical principle meaning truthfulness. It also builds trust Veracity 83. Name the three types of leadership styles Authoritarian/autocratic, Democratic, laissez fare 84. Name two things required to motivate people Power and authority 85. Pain tolerance is what type of research? Qualitative 86. Phases of decision making Define objectives, generate options, identify advantages and disadvantages, rank options and select one, implement option selected, evaluate the results 87. Phases of reality shock Honeymoon, shock, recovery and resolution 88. QI vs CQI QI - Nightengale began, structured/organized, evidence based CQI-Purpose, Identify and collect data, analyze, evaluate and change, responsibility, evaluate structure process and outcome 89. Re-admission rates are what type of research? Quantitative 90. Requirements for informed consent Mentally competent adult - voluntary, client understands exactly what they are consenting to, Consent includes risks alternative treatments available and outcomes, consent is written 91. Rights of a person participating in research/experimentation? Voluntary consent, if the subject of the research is human - they can stop at any time they choose, patients are adequately informed 92. The role of this group is to provide unbiased, expert advice to improve health. (they drive healthcare) Institute of medicine (qsen, quality and safety - we teach to the IOM) 93. Situations that increase a workers susceptibility to violence Routine contact with the public, work alone or in small numbers, work late, poor security, patients and families with weapons, lack of experienced staff, units and patients that require seclusion/restraint activities 94. Six aims for quality improvement in healthcare - (Institute of Medicine) Healthcare should be 1. safe 2. effective 3. pt centered 4. timely 5. efficient 6. equitable 95. These standards are maintained in policy and procedure manuals/online access. Developed by institutions Internal standards 96. Steps of a lawsuit Complaint, discovery, deposition, and trial 97. Steps to follow if possible lawsuit is pending Immediately seek legal counsel, never sign documents without legal counsel, notify your malpractice carrier if covered and employer, keep all correspondence (written and verbal) 98. Steps to solving a problem Gather data, analyze data, establish outcome, implement, evaluate 99. Strategies for group decision making Increase acceptance, increase time, more ideas generated the better, increase team building, all members need knowledge, some members may dominate, competition can develop 100. Strategies for groups to decide on changes Brainstorm, nominal group techniques, focus groups, delphi technique(Panel of professionals to educate) 101. Ten rules to govern healthcare reform for the 21st century as published/recommended by the institute of medicine 1. care is based on a continuous healing relationship 2. care is provided based on pt needs/values 3. pt is a source of control of care 4. knowledge is shared and free. 5. Evidence based decisions 6. safety as a system is a priority 7. secrecy is harmful, transparency is necessary 8. anticipate pt needs 9. decrease waste continually 10. cooperation needed between the healthcare providers 102. Things an RN should do when evaluating the delegation process Oversees the care, determine if pt care needs have been met, allow for feedback 103. This approach to error resolution addresses a problem and goes deeper, and deeper and deeper to find out "why" Root cause analysis 104. This budget is a plan for monthly bills and receipts Cash Budget (Petty cash) 105. This budget used by businesses is to purchase equipment Capital Expenditure budget 106. This budget used by businesses is used for day to day expenses Operating Budget 107. This drives healthcare, (QSEN standards also) IOM- Institute of Medicine 108. This ethical principle is loyalty and a promise to fulfill all commitments. (accountability) Fidelity 109. This ethical principle means being responsible for your own action to self and other collegues accountability 110. This ethical principle means "doing good" for others Beneficence 111. This finding in research means there is low probability the result was due to just chance "significant findings" (Not chance - proven probability) 112. This health practice model advocates for continued growth of nursing, provides vision, practices self and shared governance and empowerment of nursing practice Professional practice model 113. This is a health care delivery system that uses financial incentives and management controls to direct efficient and appropriate health outcomes (capitated system) Managed Care 114. This is a health care initiative by the institute of medicine that states the "Crossing the quality chasm" gaps in actual care and high quality care can be attributed to key inter- related areas within healthcare 115. This is a measure of the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current and professional knowledge Quality 116. This is a persons own code for what is acceptable behavior (conscience) this is learned Morals 117. This is a problem in which conflicts of belief exist making decisions difficult Ethical dilemma 118. This is a type of leadership in which the nurse is acting in an approved/appointed management role Formal leadership 119. This is created as an attempt to demand lower health care prices by consumers and employers. (the strongest movement in healthcare) Managed Health Care organizations 120. This is "do no harm" ethical principle nonmaleficence 121. This is leadership exercised by a person with no official power but influences others (can be positive or negative influence) Informal leadership 122. This is something in the environment that changes (research/experimentation methods) Variable 123. This is the ability to influence the beliefs, opinions or behaviors of a person or group toward overall goal acheivement Leadership 124. This is the act of getting work done through others by planning, organizing and commanding employees Management 125. This is the ethical belief that each person must be treated equally Justice 126. This is the freedom to make ones own decisions Autonomy 127. This is the law that involves the violation of one persons rights against anothers Civil law 128. This is the model in which each person in an organization share a mission, vision, values and partnerships. They believe that each person has a right to healthcare and each person is accountable to communicate and contribute to their healthcare. It is a planned partnership. Empowerment for each persons healthcare begins with themselves. Clinical Practice Model for healthcare 129. This is the negative phenomenon that occurs in highly cohesive groups similar prejudices suppress open discussion. It often interferes with critical thinking and increases pressure to conform. Group Think 130. This is the "right" or "wrong" of human behavior, and the motivation behind it Ethics 131. This is the term used for professional negligence Malpractice 132. This is the unintentional tort of acting or failing to act, resulting in harm to the person owed care Negligence 133. This liability is your individual responsibility for action or inaction Personal liability 134. This managed healthcare organization is when the physician and health services are contracted with the insurance company to provide services at discounted fees PPO 135. This managed healthcare organization type allows choice of providers but cost may be higher POS 136. This occurs when the novice RN adjusts to the Resolution new evironment 137. This occurs when the novice RN begins to understand the culture of the unit after reality shock Recovery 138. This personality test studies Extro/introversion, sensing/intuition, thinking/feeling and judging/perceiving MBTI (Myers-Briggs Type Indicator) personality testing (some employers use this to seek out possible new employees) 139. This Practice for research holds the "TRIP" value system (translating research into practice) Evidence based practice 140. This prevents some medical practices from being considered battery Informed consent 141. This process includes data information collection and knowledge. It is the infrastructure for Evidence based practice, and collects data for standardized nursing practice, Hospital information data and administrative database maintenance (collection of private, secure data) Informatics 142. This research is objective, numbers are used as analysis Quantitative 143. This research method asks "Does the tool really measure what it is supposed to?" Validity 144. This research technique combines information from multiple sources, and is quick and powerful Triangulation technique 145. This research term describes the likelihood that something will happen Probability 146. This research type is subjective, words are used as element of analysis Qualitative 147. This skill is a prerequisite for good delegation skills? Good organizational skills 148. This states that the supervisor that gives an Malpractice -(respondeat order can be sued if the person below them fails to follow it. superior) 149. This takes the value of right/wrong and applies it to life/death issues Bioethics 150. This type of civil law involves damage to a persons reputation with words, defamation of character, invasion of privacy, or breech of confidentiality Quasi-Intentional Tort 151. This type of civil law is a legal duty of care (Duty to not harm) Tort 152. This type of error event is when no harm or minimal harm is done Near miss 153. This type of error event is when serious injury occurs, very concerning, major mistake Sentinel event 154. This type of error event shouldn't have happened. Ever. Never Event 155. This type of leader is directive an controlling and can damped the creativity and inhibit motivation of the group (Very efficient) Autocratic/ authoritarian 156. This type of leader is usually characterized by guidance from the leaders, rather than control by Democratic 157. This type of leader leads people to feeling confused, without goals or guidance and is often ineffective with little control or responsibility for the leader (not efficient) Laissez-Fare 158. This type of leader makes no attempt to motivate or move the group in any direction Laissez-Fare 159. This type of leader tries to move the group toward the groups goals - Shared responsibility (Somewhat efficient overall) Democratic 160. This type of leader tries to move the group toward their own (the leaders) goals Autocratic/authoritarian 161. This type of liability is dependent on hiring of quality staff, in a safe environment Employer/Corporate liability 162. This type of liability is employers being held accountable for negligence of employees Vicarious liability 163. This type of organizational structure is less bureaucratic, more flexible, decisions are made by those who implement the changes, autonomy is emphasized, communication is up and down Innovative/Decentralized/Non-traditional 164. This type of organization gives power to those who are affected by decisions Decentralized/Non-traditional/Innovative 165. This type of resistance to change attacks the idea, refuses to change, argues, organizes resistance of other people Active resistance 166. This type of resistance to change avoids discussion, ignores the change, refuses to commit, and agress but doesn't act on the change Passive resistance 167. This was a group of recommendations by the institute of medicine to enhance safety, encourage learning from errors, sets "To Err is Human" recommendation standards for safety and safety systems 168. Tips for a successful Team conference Present the info in a clear concise manner 169. Tips for prevention of malpractice Keep informed about new information r/t your practice (CEU's), Insist on employer keeping personnel informed of all changes in policy/procedure and new technology, follow standards of care, ID at risk clients for problems, maintain safe environment, document precisely, write detailed incident reports, file incident reports, recognize client behaviors that might be a problem 170. To keep a current license RN's complete CEU's. At least one of these CEU's must be about . Pain or pain management 171. Top 3 types of quality errors that can happen in an institution 1. Service occurrences 2. serious incident 3. sentinel event 172. True or false, conflict is always a negative experience False, not necessarily 173. True or false, conflict is inevitable in large groups True 174. True or false, effective leadership ensures good management skills False 175. True or False, good management skills ensure good leadership skills? False 176. True or False, it is more difficult to provide positive feedback than to provide negative feedback? false, it is more difficult to provide "good negative feedback" Than positive feedback. 177. True or False, the courts uphold the authority of True boards of nursing to regulate standards 178. Two things (Forces) that can happen during change (according to Lewin) 1. Driving forces and 2. Resisting forces 179. Types of Civil Law Tort, Quasi-Intentional Tort, Negligence, Malpractice 180. Types of ethical values Intrinsic, extrinsic, personal and professional 181. Types of law Criminal, Civil 182. These types of tests determine probability (likelihood something will happen) statistical tests 183. These types of values sustain life - (food/water) Intrinsic values 184. What are 4 things that the Institute of Medicine states about quality of care 1. quality can be defined and measured 2. quality problems are serious and extensive 3. current approaches are inadequate to improve quality 4. there is an urgent need for rapid change 185. What are driving forces for change? They call for the change, enable it. It must increase in order for the change to occur 186. What are restraining forces of change? Resistance to change. They must decrease for the change to occur 187. What are some advantages of functional nursing care Care is provided economically and efficiently, minimum number of RNs required, tasks are completed quickly 188. What are some advantages of primary nursing care? High quality holistic patient care, Establish good rapport with RN, the RN feels challenged and rewarded 189. What are some advantages of team nursing care? High quality, comprehensive care with a high proportion of subordinate staff, each team member participates in care decision making and contributes their own expertise 190. What are some advantages to total patient care High degree of autonomy, Lines of responsibility and accountability are clear, nursing? patient receives holistic unfragmented care 191. What are some common areas for Functional nursing delivery? Operating Room 192. What are some common areas for primary care nursing delivery? Hospice, Home Health, Long Term Care, (my sub-acute detox facility I work on) 193. What are some common areas for team nursing delivery? Inpatient and outpatient care settings (Med/Surg, Pine Rest Inpatient units etc) 194. What are some common areas for Total Patient Care Nursing delivery? ICU, PACU, and Nursing students often provide total patient care. :D 195. What are some common errors of delegation? Overloading self by not delegating, old patterns of behavior, unclear communication, release of control, pressure to delegate in appropriately 196. What are some decisional behaviors of nurse managers? Employee evals, resource allocation, planning, job analysis and redesign 197. What are some disadvantages of functional nursing care? Care can be fragmented, Pt may become confused with so many different care providers, caregivers feel unchallenged 198. What are some disadvantages of primary nursing care? Primary nurse must be able to practice with a high degree of autonomy, RN must accept 24 hour responsibility, more RN's are needed so it is not cost effective 199. What are some disadvantages of team nursing care? Continuity suffers if daily team assignments vary, team leaders must have good leadership skills, There may be inefficient time for planning and communication between team members and teams 200. What are some disadvantages of total patient care nursing? Inconsistency- each RN may have different approach to care, not cost effective, Lack of RN availability 201. What are some examples Assisted Suicide, technology issues, gene of ethical dilemmas therapies, designer babies, organizational climate 202. What are some factors the RN should consider when delegating tasks? Is there potential for harm?, Complexity of the RN activity/task, what problem solving/innovation is required, how predictable is the outcome? 203. What are some fiscal responsibilities of RN's? Understand that budgeting drives healthcare, achieve patient outcomes in a safe/cost efficient manner, judicious use of equipment and supplies 204. What are some good team communication guidelines? Active listening, communicate genuine concern and interest, provide the employee with adequate information, use team members ideas in the plan of action, maximize feelings of self respect, focus on the team members ability to help themselves, don't minimize value of time allowed to learn, seek alternatives, respect values and dignity, depresonalize potential conflict situations 205. What are some informational behaviors of nurse managers? Spokesperson for staff and the organization, monitor activities of units/work groups, dissemination of information 206. What are some interpersonal behaviors of nurse managers? Networking, conflict resolution, employee development, rewards/punishment 207. What are some methods used to organize nursing care? -critical pathways, computerized information sheets, personalized worksheets, delegation trees 208. What are some possible goals of a health care organization other than "caring for the health and wellbeing of people) -Survival, Growth, Profit, Status, Dominance 209. What are some potential conflict generators in the workplace? Competition, increased workload, multiple role demands, threats to safety/security, scarce resources, cultural differences, invasion of personal space 210. What are some reasons delegation is necessary? RN shortage, health care reform, increased need for nursing services, cost containment, time management, demographic trends, use of UAP 211. What are some RN only tasks that should not be delegated? Initial teaching, nursing diagnoses, assessments, delegation to others 212. What are some roles of the nurse manager? Customer service, team building and motivation, decisions/mediation, evaluations, delegation, change agent, clinical consults, staff development, corporate supplier 213. What are some things that can make groups (in general) feel more empowered? Joining/participating in Professional organizations, collective bargaining, shared governance 214. What are some trends in informatics today? EMR/Smartcards, telehealth, email help, health websites and evaluation of web resources 215. What are some types of errors that can occur in healthcare delivery Diagnostic, treatment, preventative 216. What are some ways in which nurses feel empowered? Assist with decision making, Keeping workloads manageable, reward/recognition, fairness/equality 217. What are some ways to lower resistance to change (Restraining forces) Information dissemination (give as much info as possible for better understanding), Disconfirm currently held beliefs(risks if a change does happen), Psychological safety must be ensured, Command (usually commanding doesn't work) 218. What are the 2 times in which confidentiality may be violated? If the pt is indicating they may harm themselves or others, if the pt gives permission for the information to be shared 219. What are the 5 rights of delegation a nurse must remember? Right task, Right circumstance, Right person, Right direction/communication, Right supervision/evaluation 220. What are the differences between mission statement, vision and philosophy of an organization Mission - reason for existence, Vision- goals/ambitions for future, Philosophy-value of principles/beliefs/behaviors 221. What are the different types of nursing -Professional practice model, - Clinical practice model practice models 222. What are the key things that should be included in shift change report? Pt ID, Pt Dx, Where the pt is, Treatment plan, Responses to treatments, omit personal opinion and judgement 223. What are the main components of michigans professional health recovery program? Intake, referral, treatment, recovery monitoring and completion 224. What are the qualities of a good leader? Integrity, courage, initiative, energy, optimism, perseverance, balance, ability to handle stress, self awareness 225. What are the requirements of the patient self determination act Advanced directives - (Each person must be provided with information regarding them, documentation must be made, education necessary, respect pts rights, demonstrate cultural humility) 226. What are the skills needs of a novice RN? Interpersonal skills, Clinical skills, organizational skills, delegation skills, prioritization skills, improved social skills 227. What do followers expect from good leadership? Respect, tools to do the job, guidelines/input into the decision and how it will affect them as followers, openness to change, quality relationships with supervision, rewards/recognition, balance of life, professional development opportunities 228. What happens if a student doesn't pass NCLEX after 3 x in one year Must have to repeat an RN program. Then gets 3 more chances in 12 months to pass (this may vary state to state) 229. What impact do ineffective nurse managers have on others? Can harm employees, clients and the organization for which they work 230. What is evidence based care model standards to follow? Ask a clinical question, acquire the evidence, appraise the evidence, apply the evidence to practice, assess the outcomes 231. What is formal Written policies set in stone power? 232. What is horizontal delegation" RN to RN (transfer of responsibility and accountability) Transfer to person of same expertise level. 233. What is informal power? Powers under the radar (stems from relationships you build/rapport etc - the way you speak to certain people can gain you power) 234. What is SWOT analysis? Strengths, weaknesses, opportunities, threats 235. What is the difference between delegating and assigning? Delegate- RN remains accountable (verticle RN to UAP), Assign-Transfer of responsibility (Horizontal RN to RN) (verticle -responsibility of the task if transferred to the delegatee, accountability remains with the delegator) 236. What is the difference between Theory X and Theory Y (McGregor) Theory X - Work is avoided, people want to do as little as possible, control and punishment is needed. Theory Y - Work itself can be motivating/rewarding, people actually want to do their job well, guidance and development with rewards are needed 237. What is the purpose of a mission statement? To show purpose/reason for existence, outlines aim of organization, critical in strategic planning and guides planning 238. What is the purpose of belief systems To explain concepts such as life and health, good and evil, and health and illness 239. What is the purpose of peer review? To provide the individual with feedback from those best acquainted with the requirements and demands of the position. 240. What is the role of the staff nurse pertaining to budget? Control spending /cost on the unit without compromising patient safety 241. What is the safety goal of JCAHO? Improve communication among health care providers 242. What is the staff RN role in research? Ensure rights, Identify problems, assist with research, implement findings, read widely and critically, attend conferences, seek an environment in support of research, journal clubs, collaborate with researchers 243. What is vertical delegation? From Rn to less qualified or UAP (RN is still accountable) 244. What should the nurse consider when implementing delegation to staff (assignments) Assign appropriate personnel who have the level of expertise necessary to deliver the care or carry out the activities. 245. What three traits are necessary in a person to prevent burnout 1. a sense of personal control rather than powerlessness 2. commitment to work and lifes activities rather than alienation 3. seeing lifes demands and changes as a challenge rather than a threat (THINK POSITIVE) 246. What to do if workplace safety is compromised Report to supervisor, call police, get medical attention, contact union/collective bargaining/ nurses association, participate in policy making 247. What type of law states that nurses have a duty to deliver care in such a manner that pts will not be harmed? (civil law) Tort 248. What were some reasons for the crossing the quality chasm initiative from the institute of medicine? Growing complexity of science and technology, increase in chronic medical conditions, poorly organized delivery of care system, constraints on exploiting the revolution in information technology 249. When must the NCLEX be taken within two years of graduation 250. Where does funding for research come from? Private foundations, nursing organizations, government (organizations NIH, Dept of Health and human services) 251. Who is responsible for RN disciplinary action? State boards of Nursing 252. Why are clinical pathways used? To decrease cost (save money) HESI LEADERSHIP 1. Charge nurse takes over for nurse on break, which client checked first -40ml dark colored urine 2. UAP stuck in palm by needle with Hep B -wash hands with soap and water 3. Assess first -coronary syndrome with increasing SOB 4. New clinical documentation -Need to discuss new clinical documentation that helps save lifes and require one more document 5. PCA to PO. BP increases 120/72 to 150/90. Additional questions/comments to HCP -can PCA be reinitiated 6. Most immed, intervention by nurse -pneumothorax with 80 o2 7. Intervention best to delegate to LPN - Fentanyl (Duragesic) – narcotic med 8. Morning lab, follow-up first -BNP- Brain narcotic peptide test, MI with SOB 1000 9. UAP to assemble nephrostomy tube -change bag to leg bag 10. Women health fair, PN helping RN -assist with bone density prep 11. Warrants immediate attention -female with RLQ pain in abd, febrile and vomiting 12. Delegated to UAP -apply abd binder 13. Multidisplinary team -elderly man with BGL 400 Assess first -constipation -weakness -pressure ulcer with skin flap -hep A 14. Triaging ER client assess first -elderly -child -female -male 15. 67 y/o female client recently widowed, increased confusion/disorientation. -medical eval, managed healthcare plan 16. Female resident who is mentally alert and lives in a long-term care facility reports that a staff member slapped her -does she know the name of the person 17. Most important to assign which client to a RN rather than PN -Pain scale of 9 18. PN reports to RN, patient pulled out CVC, UAP is with him in room. Stat dose of oral antianxiety med. RN assign care -RN with CVC, PN stat med, UAP VS on new admission 19. Charge nurse is making assignments for a 15 bed skilled nursing unit with staff of one RN, 2 LPNs, and 2 UAPs which assigned to RN 20. Order women with history of HTN transferred from long-term to ICU b/c of HF, has DNR (SATA) -BP, MAP 92 -body weight daily -prepare family for end of life -monitor urine 21. RN assigned to care for four surgical clients. Which client should nurse see first. -3 postop, 1 preop 22. The nurse is caring for a group of clients on a surgical unit. What action should the nurse implement first -prepared for OR 23.0200 nurse phones HCP to request med for client who is unable to sleep four times the the dose. Nurse questions, HCP sleepy says “yea, ok” action first -call HCP about dosage 24. Watches UAP bring soap, washcloths, and towels and a basin into room with male client who has suprapubic catheter inserted earlier today. 25. Telephone triage at clinic office. Which client is most acute and should be scheduled for the first available appointment. -21 y/o with kidney transplant, fever of 102, flu-like symptoms 26. Nurse should assess the client with which problem first -arterial occlusion 27. RN gathering supplies to assist HCP with bedside thoracentesis when ED calls to report on a client with unstable angina -PN assist with thoracentesis, RN gets report, UAP prepares room 28. UAP give bath and change bed linen on Kaposi sarcoma (associated with HIV) -tell UAP to wear gloves and gown when handling linen 29. Safely assess last drainage -Jackson-Pratt, no postop drainage after 8 hours 30. Postop RR decrease from 14 to 6 after opioid. 30 minutes later decreases to 4. Narcan given -why wait so long to call HCP 31. Nurse determines that an IV vesicant chemo infusion is infiltrated -apply cold compress 32. Nurse planning care for 4 postop clients, different drainage systems 33. 5 y/o boy with mumps is transferred to the peds unit. Nursing intervention most important to implement? -PPE cart placed in front of the clients door 34. Evening shift on med unit is busy, only nurse on the unit is busy with an unstable patient. HTC is on the phone with the unit secretary for an order for OTC laxative PRN. What is the best response? -the nurse will call you back as soon as possible to obtain the order 35. Elderly male who is ketoacidotic becomes agitated when the nurse attempts to orient the client to time and place. What room is the best for this client? -the room next to nurses station 36. Pt diagnosed with unstable angina is scheduled for cardiac cath. Select all. -assess chest pain or armpit pain, check pulses on both feet, assess groin access site, monitory VS per post op protocol. 37. Nationally known management consultant is expensive and is here to give a presentation at a local hospital. What is the best way to make sure that the information is received and passed onto other staff members? -send 2 nurses to get information 38. Making assignments for the day, which info provided during change of shift report is most important for the charge nurse to consider? -elderly female client who refuses to be cared for by a male nurse 39. Patient being transferred from PACU, what would finish the report… cardiac patient -when was the last narcotic given 40. Patient being transferred from PACU, what would finish report -absent bowel sounds.. 41. PN observes that LPN performed a dressing change. But when the PN goes the check the patient she notices that the dressing is 2 days old. What should the PN do first? -consult the LPN about the discrepancy 42. Which client is assessed first at the beginning of the shift -acute abdominal pain 43. Iv on male client admitted with sepsis. UAP told to get VS. UAP reports that skin is flushed and dry with temp of 102 HR 120, RR 24. What should the nurse delegate to the UAP -ask client if in pain 44. UAP has restrained a female client to a wheel chair and the client is asking to be untied. The UAP explains to the nurse that this is the only way she can put new sheets on the patient’s bed. What action should the CN take? -advise the UAP to remove the restraints immediately 45. Charge nurse is making assignments in an inpatient psych unit. Which task should be given to the LPN -admin of routine meds 46. Upon morning shift, which patient do you assess first -40 y/o with triple A-Abdominal aortic aneurysm and low back pain 47. concern about physician procedures- REPORT PHYSICIAN! 48. picture of gastronomy tube- STOP MED ADMINISTRATION 49. budget cuts- TAKE NURSE TO PRIVATE ROOM 50. narcan question- WHEN TO CALL HCP 51. which should be assigned to the rn?- BILATERAL AKA- above the knee amputation . NOW HAS A SACRAL DECUBITUS SKIN FLAP 52. receiving end of life home care, pt is cachexic ( weakness) - ONLY ABLE TO TAKE SIPS 53. pn tell nuse doesn’t want to do procedure- TELL PN ASSISTANCE IS AVAILABLE BUT SHE IS RESPONSIBLE FOR CARE 54. orientee overwhelmed, beem out of work 10 years- ASSIGN ORIENTEE TO WORK WITH EXPERIENCED NURSE 55. discharged from ambulating after varicose vein stripping teaching- ELEVATE FOOT OF BED WHILEIN BED 56. asa scheduled at 0900, complaints of pain at 0800- OBTAIN PRESCRIPTION FOR PRN ANALGESIC 57. reading back hcp prescription, most important to implement- INITIATE TELEMETRY &OBTAIN CARDIAC RHYTHM 58. peripheral infusion site of a blood transfusion- ECCHYMOTIC…SWOLLEN 59. – ASK COWORKER TO RESPOND TO THE CLIENT WHOSE CALL BELL IS RINGING HESI Leadership • A client who weighs 65 kg is receiving an infusion of dopamine 400 mg in 250 ml of D5W at 12 ml/hour. How many mcg/kg/min is the client receiving? o 4.9 • The nurse is planning for the care of a 30•year•old primigravida with pre•gestational diabetes. What is the most important factor affecting this client’s pregnancy outcome? o Degree of glycemic control during pregnancy • Which statement is an example of correctly written nursing diagnosis statement? o Ineffective coping related to response to positive biopsy test results. • The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? o 0.5 ml • What description encompasses the role in client care management played by nursing informatics? o The input and retrieval of electronic data about a client’s medical history • When evaluating a client’s plan of care, the nurse determines that a desired outcome was not achieved. What action will the nurse implement first? o Note which actions were not implemented • Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach? o Give one hour before or two hours after a meal • A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement first? o Apply a Fox shield to the affected eye and any type of patch to the other eye • A client who has a miscarriage at 10•weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client’s statements, which action should the nurse implement? o Ask the client what name she had picked out for the infant • A 24•hour•old newborn has a pink popular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? o Document the finding in the infant’s record • The nurse is caring for a 9•year•old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? o Ascertain what the child understands about sex • A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. What response should the nurse provide? o Look for early signs of a lesion that increases in size with red border, clear center • A child receiving maintenance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20. How many milliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? o 61 • An anxious client expressing a fear of people and open places admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? o Accompany her outside for an increasing amount of time each day • The nurse providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? o Report uterine cramping or low back pain • Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? o Upon discharge, the client will list three ways to protect the feet from injury • A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse’s greatest concern? o Accused of diversion • A 32•year•old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client’s complaints? o Inability to get pregnant • An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? o Check for areas under the straps three times a day • A 9•month•old infant receives a prescription for digoxin 40 mcg PO daily. Digoxin Oral Solution, USP 50 mcg (0.5 mg) per ml is available. How many ml should the nurse administer? o 0.8 • A female client with insulin•dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? o Maintain blood sugar levels in a constant range within normal limits during pregnancy • The father of an 8•year•old tells the nurse he is interested in seeing his child succeed in soccer. The nurse talks with the boy, who expresses a sincere interest in playing chess and feels like a failure at soccer. How should the nurse respond to this father? o The child should be given opportunities to achieve a sense of competency in area he chooses • The nurse is evaluating a client’s response to diuretic therapy. Which assessment provides the best measure of the client’s fluid volume status? o Intake, output and daily weight • The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left•sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? o Move the chair parallel to the right side of the bed, and stand the client on the right food • An older female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left•sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, “If it will help.” The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother’s original request, which was executed when she was healthy. What information is best for the nurse to provide. o The family should be guided to support the client’s current decision about the ventilator • The community health nurse is planning a series of educational courses about the healthcare system and meeting healthcare needs for community center. Which adjunct issue should the nurse address for a group of older adults? o Retirement issues • When assessing a client prior to the administration of digoxin (Lanoxin), which data is most important for the nurse to consider? o Irregular apical pulse with rate of 87 • A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? o Continue breast feeding every 2 hours • Four clients arrive on the mental health unit for admission at the same time. Which client should the nurse assess first? o A middle•aged adult with acute mania who is pacing the hallway • Which symptoms should the nurse expect a client to exhibit who is known to have phenochromocytoma? o Headache, diaphoresis, and palpitations • When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority? o Hypertension • A nurse who works in an acute minor illness clinic returns from lunch and finds several clients who need attention. Which client should the nurse attend to first? o A 4•year•old receiving intravenous fluid for dehydration whose IV fluid bag is empty • The nurse receives report in the emergency center for four clients. Which client should the nurse assess first? o A client experiencing shortness of breath and dyspnea HESI LEADERSHIP / MANAGEMENT 1. Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? Correct 1 Registered nurse 2 Licensed practical nurse 3 Primary health care provider 4 Unlicensed nursing personnel The registered nurse is accountable for the initial assessment and ongoing evaluation of the client. A licensed practical nurse is not accountable for initial assessment and ongoing evaluation of the client. The primary health care provider is accountable for diagnosing the problem and reviewing the client responses. An unlicensed nursing personnel performs the tasks delegated by the registered nurse or other delegators. 2. Which team member is most accountable when delegating a task to the healthcare team? 1 Certified technician Correct 2 Registered nurse (RN) 3 Licensed practical nurse (LPN) 4 Unlicensed assistive personnel (UAP) The registered nurse (RN) on the healthcare team is most accountable when delegating a task to the team. The certified technician on the healthcare team is responsible for the assigned task. Similarly, the LPN and UAP are also responsible for the assigned task. 3. Which healthcare professional would the nurse know is held accountable for the tasks performed by the patient care associate (PCA)? Correct 1 Registered nurse (RN) 2 Licensed vocational nurse (LVN) 3 Unlicensed assistive personnel (UAP) 4 Unlicensed nursing practitioner (UNP) The delegator is held accountable for tasks performed by the delegatee. In this situation, the delegator is the RN; therefore, the RN is held accountable for the tasks performed by the PCAs. The RN is also accountable for delegation to LVNs, UAPs, and UNPs as delegatees. 4. The registered nurse is evaluating the statements made by a student nurse after teaching ways to make appropriate delegation decisions. Which statement made by the student nurse indicates a need for correction? 1 "The delegatee should report the findings back to the delegator." 2 "The delegatee should understand the assigned task completely." 3 "The delegator should trust the delegatee to accomplish the task." Correct 4 "The delegator should recheck and redo the work of the delegatee." Time management is an important part of an appropriate delegation process. If the delegator rechecks and redoes the work of the delegatee, it increases the time to accomplish the task and results in inappropriate delegation. Reporting the findings back to the delegator helps the delegator to understand the progress of the task. The delegatee should understand the task completely to perform as desired by the delegator. Trusting the delegatee reduces time to do the task and build a healthy working environment. 5. Who would the registered nurse state is accountable for establishing systems to communicate competency requirements related to delegation? 1 Registered nurse (RN) Correct 2 Chief nursing officer (CNO) 3 Licensed practical nurse (LPN) 4 Unlicensed assistive personnel (UAP) CNOs are accountable for establishing systems to communicate competency related to delegation. The registered nurse delegates the task to LPN and UAP. In delegation, the RN implements in clinical practice to improve the safety and quality of client care. LPNs provide direct care to the client. UAP provide direct care to the client under the supervision of the registered nurse who retains accountability for client care outcomes. 6. The registered nurse (RN) and unlicensed assistive personnel (UAP) have been working together for two years. Which statement made by the RN would be appropriate after delegating a task to the UAP? 1 "Let me tell you how to do this task." Correct 2 "You know what to do and when to report." Incorrect 3 "Please tell me how you are going to perform this procedure." 4 "It is important that you check the client’s temperature every hour." According to Hersey’s model of situational leadership, the delegator should act according to the situation. When there is an established relationship between the delegator and the delegatee, little guidance needs to be provided to the delegatee. When the relationship is new and a new task is delegated, an explanation is required about how to perform the task. When the delegatee is newly assigned, then the delegator checks the ability of the delegatee by asking how to perform the procedure. When the relationship between the delegatee and delegator is new, and it is for a limited period, then the delegator just informs the delegatee what is to be done. 7. The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations? 1 Nursing aide 2 Certified technician 3 Patient care associate Correct 4 Licensed practical nurse Tetanus vaccination is administered through the intramuscular route. The licensed practical nurse can administer oral, topical, and intramuscular medications, except for intravenous. The nursing aide, certified technician, and patient care associate are unlicensed assistive personnel whose scope of practice is limited for administering medications. 8. A client who sustained a leg fracture is prescribed intramuscular analgesic medication. Which healthcare professional can be safely delegated this task? 1 Registered nurse (RN) 2 Patient care associate (PCA) Correct 3 Licensed practical nurse (LPN) 4 Unlicensed nursing practitioner (UNP) An LPN is authorized to administer oral and intramuscular drugs. An RN is a delegator, who can administer intravenous drugs. PCAs and UNPs are unlicensed personnel who can perform tasks such as positioning the client and maintaining the hygiene of the client. 9. Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply. 1 Analyzing vital signs 2 Maintaining oral hygiene 3 Administering intravenous drugs Correct 4 Administering oral hypoglycemic agents Correct 5 Administering intramuscular medications Licensed vocational nurses and licensed practical nurses are authorized to administer drugs through oral and intramuscular routes. Analyzing vital signs should be performed by the registered nurse. Hygiene maintenance can be delegated to unlicensed nursing practitioners (UNP). Administering intravenous drugs should be done by the registered nurse. 10. A nurse manager transfers the task of caring for a client who has undergone appendectomy to a registered nurse (RN). Which element of the healthcare system is the RN practicing? 1 Delegation 2 Leadership 3 Supervision Correct 4 Assignment Both accountability and responsibility are transferred from one person to the other in assignment. When a nurse manager delegates the task of client care to an RN, responsibility is transferred to the RN. The nurse manager shares accountability with the RN in delegation. The nurse manager, as leader, manages the healthcare team and delegates tasks to members of the healthcare team. In supervision, the nurse manager oversees the RN in completing the task. 11. Which employee should be competent in critical thinking, leadership, communication, and time management skills? Select all that apply. Correct 1 Charge nurse 2 Student nurse Correct 3 Registered nurse 4 Unlicensed personnel 5 Licensed practical nurse The charge nurse and registered nurse should each have a sophisticated level of competency in critical thinking, leadership, communication, time management, clinical practice, and organization. These skills are helpful for the charge nurse or the registered nurse to serve as a delegator. The student nurse, unlicensed personnel, and licensed practical nurse do not delegate, because they are less skilled than the charge nurse. 12. Which healthcare team member is responsible for the coordination and assignments of client care? Correct 1 Charge nurse Incorrect 2 Nurse manager 3 Chief nursing officer 4 Patient care associate A charge nurse coordinates care and assignments and will ultimately be the only person who is familiar with all the needs of any individual client. A nurse manager is responsible for managing the staffing and delegation aspects of the healthcare team. The chief nursing officer is responsible for establishing the systems for assessment and checking the requirements for competent work of the team members. A patient care associate is responsible for providing basic care to the client. 13. What is the main motto of the Hersey’s 2006 model? 1 Information decay 2 Information salience Correct 3 Situational leadership 4 Individual accountability Hersey’s 2006 model provides a solid foundation for delegation decisions. The main motto of this model is situational leadership. The core competencies of a situational leader are the ability to diagnose the performance, competence, and commitment of others; to be flexible; and to partner for performance. Anthony and Vidal describe characteristics of communication that interfere with the delegation process, such as information decay. They also describe information salience, or the quality, meaning, and clarity of the information. Ana mentioned individual accountability, the expectation of accountability and responsibility in 2011, specifically referencing delegation. 14. Which characteristic should the nurse use during the nursing process as a guide for delegation? 1 Leadership Correct 2 Critical analysis 3 Psychomotor task 4 Time management Critical analysis by the registered nurse serves as a guide for delegation in the nursing process. It is applied in assessment, planning, implementation, and evaluation for safe and effective client care. Leadership is a role in which a nurse has charge of the personnel as they perform their tasks. Psychomotor tasks are the common characteristics and essential components that a nurse should possess to provide client care. Time management is essential in performing tasks within specified deadlines during delegacy. 15. Which work is automatically increased for the delegator when there is a decrease in direct client care? 1 Leadership Correct 2 Supervision 3 Delegation 4 Assignment After delegating tasks to other members of the health care team, the delegator’s care towards the client in a direct way decreases, and the supervisory work of the delegator increases. Leadership work does not necessarily increase when there is a decrease in direct client care. Delegation and assignment of work does not increase, because the work has already been delegated to another health care team member. 1. The newly hired nurse is delegated the task of preparing the client care plan for a diabetic client who underwent amputation. Which task in the care plan is inappropriate according to guidelines? 1 The registered nurse (RN) administering antidiabetic medications Correct 2 Instructing the licensed practical nurse (LPN) to monitor vital signs 3 The RN assessing the client’s blood glucose levels at regular intervals 4 Instructing the licensed practical nurse (LPN) to change the dressing at the amputation site The LPN’s scope of practice includes monitoring vital signs in clients with a stable condition. Instructing the LPN to monitor the vital signs of a client in an acute condition is inappropriate according to the guidelines. Administering antidiabetic medications to a diabetic client who underwent amputation should be done by the RN because the condition of the client is acute. The RN is responsible for assessing the blood glucose levels of the client who underwent amputation. The LPN is instructed to change the dressing at the amputation site. After assessing the conditions of four clients, the nursing manager is planning to delegate tasks to the members of the healthcare team. Which client care should be delegated to an unlicensed assistive personnel (UAP) to achieve effective outcomes in care? 1 Client A The UAP is eligible to assist and take the client’s vital signs post surgically, so an effective outcome can be expected if this task is delegated to the UAP taking care of client D. Ear irrigation in client A should be performed by the licensed practical nurse. In client B, medication should be provided along with cleaning and dressing so this task should be delegated to a licensed practical nurse. In client C, urine output should be monitored by the registered nurse. 3. Which delegatee requires little guidance from the delegator? Correct 1 Delegatee who is familiar with the task but not the client 2 Delegatee who has experience but is unfamiliar with the task 3 Delegatee who has little experience but has willingness to do the task 4 Delegatee who is very familiar with the client but has a lack of ability to do the task A delegatee who has experience and is familiar with the task requires less guidance and support from the delegator as he or she has the ability to accomplish the task. A delegatee who has work experience may have ability but requires guidance as he or she is new to the delegated task. A delegatee who shows willingness to do the task but has little experience requires supervision. A delegatee who is familiar with the client but has a lack of ability to do the task requires supervision or guidance. 4. Which statement about the delegatee condition is true regarding "selling"? 1 The delegatee has established relationships and expertise. Correct 2 The delegatee has ongoing relationships; however, the task is new. 3 The delegatee has limited knowledge and ability to perform the task. 4 The delegatee has willingness and ability, but the relationship is new. "Selling" in context with delegation represents an ongoing relationship with a new task being delegated. "Participating" in the context of delegation includes willingness and ability to perform a task with a new relationship. "Telling" in the context of delegation includes limited knowledge and ability to perform the task by the delegatee. "Delegating" in context with delegation represents established relationships and expertise. 5. What is discussed in Hersey’s 2006 model related to delegation? 1 Five rights of delegation 2 Legal authorities for delegation 3 Characteristics of communication Correct 4 Core competencies of a situational leader Hersey’s model describes situational leadership, which include the core competencies of a situational leader. Anthony and Vidal described the five rights of delegation. Hersey’s model does not include the legal authorities for delegation. Anthony and Vidal described characteristics of communication, such as information decay and information salience. 6. Which question does the registered nurse recognize as related to the right of circumstance when delegating? Correct 1 "Is the delegation appropriate to the situation?" 2 "Is the task within the delegatee’s scope of practice?" 3 "Is the prospective delegate a willing and able employee?" 4 "Is the delegator able to monitor and evaluate the client appropriately?" The question, "Is the delegation appropriate to the situation?" is related to right circumstance. The question, "Is the task within the delegatee’s scope of practice?" is related to right task. The question, "Is the prospective delegate a willing and able employee?" is related to right person. The question, "Is the delegator able to monitor and evaluate the client appropriately?" is related to right supervision. 7. The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? 1 Nurse aide 2 Certified technician Correct 3 Cross-trained technician Incorrect 4 Licensed vocational nurse (LVN) A cross-trained technician is suitable for monitoring electrocardiography in a client who underwent bypass surgery. A nurse aide is an unlicensed individual who can assist the client with basic hygiene; this aide cannot monitor electrocardiography. A certified technician is also an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A licensed vocational nurse (LVN) can administer oral and intramuscular medications and record the vital signs. 8. 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? 1 Selling Correct 2 Telling 3 Delegating 4 Participating The relationship between the delegator and the delegatee is limited if the delegatee is only working for a half day in the healthcare unit. Therefore, the most appropriate leadership style in this situation is telling because it provides a fair amount of guidance but limits the time spent on the interactions. The leadership style of selling requires more time because the delegator needs to understand the delegatee’s motivation related to the situation. Delegating is the leadership style when the relationship between the delegator and delegatee is well established and the delegatee spends more time in the healthcare organization. Participating is the leadership style of sharing and exchanging views, which requires more time and an ongoing relationship between the delegator and the delegatee. 9. Which characteristic of the nurse as a delegator is reflected in the statement, "Let me show you how this procedure is done; then you can do it yourself"? Correct 1 Doing 2 Asking 3 Offering 4 Delegating Doing occurs by demonstrating the specific task or behavior to improve client care. The statement, "Let me show you how this procedure is done; then you can do it yourself," indicates doing. Asking begins with questions related to the problem or issue regarding client care and can open lines of communication between the delegator and the delegatee. Offering involves making a suggestion to facilitate the achievement of a desirable outcome. Delegating refers to transferring responsibility for the performance of a task nurse or delegator to the delegatee while retaining the accountability for the outcome. 10. A client with chronic asthma is being cared for in the inpatient care unit. To assess the client on a regular basis would be delegated to which healthcare team member? 1 Charge nurse Correct 2 Registered nurse 3 Patient care associate 4 Licensed practical nurse The registered nurse is a licensed nursing professional and is responsible for assessing the asthmatic symptoms of the client for providing care. The charge nurse is responsible for the coordination and assignment of tasks for the client’s care. The patient care associate is an unlicensed assistive personnel whose scope of practice is limited from assessing the client. The licensed practical nurse does not assess the client’s condition, but rather is responsible for providing treatment prescribed by the healthcare provider and delegated by the RN. 11. A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? 1 Monitoring the vital signs 2 Evaluating the client response 3 Gastric suctioning through vented tube Correct 4 Emptying and measuring the gastric drainage Unlicensed assistive personnel (UAP) scope of practice is limited to providing basic care, comfort, and hygiene. The UAP can measure the drainage and report the finding before emptying it. Unlicensed assistive personnel (UAP) can monitor vital signs only for clients in a stable condition. This client has an acute condition, so monitoring the vital signs is the role of registered nurse. Evaluating the client response is the role of registered nurse. UAP may perform all hygiene tasks; however, gastric suctioning through a vented tube is not within the scope of practice of the UAP. 12. A registered nurse (RN) and newly hired licensed vocational nurse (LVN) are caring for a client with chronic obstructive pulmonary disease (COPD). Which statement made by the RN would be appropriate according to the participation style of Hersey’s model of leadership? 1 "Monitor the respiration rate every half-hour." Correct 2 "Please show me how you determine respiration rate." Incorrect 3 "Let me show you which activity is necessary to perform." 4 "I am sure you know what to do when the respiration rate is abnormal." The participation style of leadership is implemented when the delegator has the willingness and ability to perform the activity and the relationship is new. In the participation style, the delegator needs to communicate with the delegatee by asking questions about how the activity is performed and by sharing the expectations. When the delegator has limited knowledge and no willingness to perform the activity, then the style should be telling, where the delegator informs what to do, such as, "Monitor the respiration rate every half-hour." In the selling style, the delegator provides supervision by telling how the activity is performed, such as, "Let me show you which activity is necessary to perform." When the relationship is already established, then the delegator implements the delegation style of leadership, such as saying, "I am sure you know what to do when the respiration rate is abnormal." 13. Which characteristics of a licensed practical nurse should be considered before delegation of tasks? Select all that apply. Correct 1 Critical thinking Incorrect 2 Effective client care Correct 3 Diagnostic reasoning Correct 4 Synthesizing information 5 Accountability of assigned task Critical thinking, diagnostic reasoning, and the ability to synthesize information from various sources are three factors that are characteristics of the licensed practical nurse that should be considered before delegating tasks. Planning effective client care is the role of a registered nurse. Accountability for an assigned task is the basic responsibility of a nurse. 14. The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case? 1 Performing hygiene tasks 2 Taking and reporting vital signs 3 Administering oral pain medications Correct 4 Developing a treatment plan for client’s pain The role of the RN is to develop a treatment plan for the client’s pain. All hygienic tasks are performed by unlicensed nursing personnel. Administering oral pain medications is done by the licensed practical nurse. Taking and reporting vital signs is done by the licensed practical nurse. 15. What does the nurse say is the advantage of an appropriate delegation? Incorrect 1 Assistance 2 Accountability 3 Empowerment Correct 4 Reduced stress Appropriate delegation reduces stress and increases time efficiency by providing timely care to the client. Assistance or direction is asked by the delegatee to complete the task if the nurse provides limited information on an assigned task. The nurse is accountable and responsible for the task assigned to the delegatee if the delegation does not work properly. Delegation requires empowerment of the delegatee to accomplish a task. 1 HESI LEADERSHIP hospice nurse end of life care- MUCOUS MEMBRANE MOIST new policy to prevent med errors- EXAMINE MED ADMINISTRATION DATA TO DETERMINE USE OF NEW PROCEDURE old client to rn (going to give to most experienced nurse)- 72 YEAR OLD WITH DM 1 4 clients, iv infusing- CEFTATRIAXONE IN 5% DEXTROSE uap, colostomy- RECORD AMOUNT charge nurse, rn, pn- CARDIAC CATH, NO PEDAL PULSES fall risk precautions- MINI MENTAL STATE EXAM client with dka- HOURLY GLUCOSE CHECKS male with metastic lung cancer- ASK PALLUTIVE TEAM TO TALK TO CLIENT 10. male with pneumonia- O2 SAT, (CONFUSED) 11. SATA: 0730 2 clients with dm- DELIVER MEAL TRAYS, PERFORM CAP GLUCOSE MEASUREMENTS 12. charge nurse assigns to pn- TELL PN THAT ASSISTANCE IS AVAILABLE 13. women with metastic pancreatic cancer- GIVE DETAILED REPORT 2 sterile procedure, code blue- FINISH PROCEDURE old client with septic shock- MAINTAIN INTAKE & OUTPUT surgical unit, who first?- DETERMINE IF READY TO GO TO SURGERY prc- DOCUMENT BEFORE ASSESSING PT’S teaching program- COMPARE INFECTION BEFORE AND AFTER pneumonectomy 4 hrs ago- ASK COWORKER TO GET CALL BELL gastric bypass surgery 2 weeks ago- REPLACE FLUIDS IV staff shortage snow storm- TEAM ASSIGNMENTS pt’s on medical unit who first- 10 YEAR OLD BOY WITH CHEMO respiratory therapist, phlebotomist- PROVIDE WITH FEEDBACK lpn lumbar puncture- DEMONSTRATE HOW TO POSITION BETTER rn and pn- ADDISON’S CRISIS nurse to pt ratio 25%- DISSEMINATE FACTUAL INFO fire alarm- KEEP CLIENT’S IN ROOMS WITH DOORS CLOSED older rn complaining- ENCOURAGE HER TO SHARE CONCERNS rn vital signs with hf- THE RN SHOULD GO FIRST IN ORDER 2 clients admitted at once- A PN TO MONITOR PT WITH COPD 3 adolescent unit- MENTAL HEALTH TECHNICIAN bedside thoracentesis- ASSIGN PN TO HELP, RN OBTAINS REPORT, UAP ROOM client pulled out cvc- RN PROVIDE CARE, PN ADMITS STAT MED, UAP OBTAINS VITALS 34. SATA: 5 clients, for uap- POST OP VITALS, HYGIENE nurse calling for help to staff unit- THE AQUITY LEVEL fall precautions- MINI MENTAL EXAM pt with influenza- REVIEW NEED FOR FACE MASK mi 4 days ago- EXPLAIN RIGHT FOR VISIOR TO LIE IN BED peer review committee- DOCUMENTING BEFORE ASSESSING screening committee interview- OLDEST CHILD, BSN, PLAYED VOLLEY BALL electrolyte imbalance edema- DISCUSS LOW SODIUM DIET gastric bypass 2 weeks ago- REPLACE FLUIDS assess which pt first- 50 YEAR OLD DX WITH AORTIC ANEURYSM delegate to uap- REINFORCE TEACHING ON CALL BELL room checks, mental health- MENTAL HEALTH TECH 4 assign to rn- OLDER ADULT WITH CARDIAC CATHERIZATION WITH ABSENT PEDAL PULSE 47. –MUST BE PALPABLE WITH DOPPLER WITHIN 24 HRS – RECEIVED NEED TO UAP TO WEAR FACE MASKWITH CLOSE CONTACT, DROPLET PRECAUTIONS cost benefit for equipment- CAN OTHER UNITS USE IT TOO anastomosis- REPLACE FLUIDS uap + a client with dka + dehydrated- REPORT BLOOD GLUCOSE mini mental state exam- 22? R 0 <23 53. -PN MONITOR COPD & RN ADMITS OVERDOSE who discovered the incident?- MENTAL HEALTH TECHNICIAN pt with dvt on warafin-MONITOR FOR SIGNS OF BLEEDING (V1 START) litigation- discuss how to handle complaints SATA: COMPLETES BED BATH, GIVE MOUTH CARE, EMPTY OSTOMY college student- MONITOR ECG CONTINUOUSLY 4 clients- DIABETES HX OF CAD older women with heroic measures- DEFINE HEROIC MEASURES 5 cushings- CONTINUE WITH PREP OF SURGERY curricula- SKILLS OF STAFF AND CLIENT ACUITY iv vesicant with chemo- REAPPLY COLD COMPRESS rn rather than pn- 1 HR AFTER RECEIVING DILAUDID male client fell, loc- INCREASING CONFUSION OF THE CLIENT hx of vertigo- HX OF AFIB & HYPOGLYCEMIA sputum collection- KNOWLEDGE ABOUT HIV TRANSMISSION diabetic clinic, pn- PERFORM DRESSING CHANGE ANKLE ULCER uap, temp 101- OFFER 120ML FLUID women with hx of high bp- CONFIRM RESUSCITATION WITH CLIENT & FAMILY consultant, fee is high- ASK 2 STAFF MEMBERS TO ATTEND ada of 1990- NURSE WITH BACK INJURY LIFTING CLIENTS SATA: BODY TEMP, REDUCED WBC, NEGATIVE URINE CULTURE new computerized machine- EXPLAIN ITS DESIGN TO REDUCE ERRORS pt doesn’t want to be weighed- ASK PT WHY charge nurse sees new nurse with liquid med- DIRECT NURSE TO STOP MED 6 clients bp 80/40- WHAT’S THE CLIENT’S PULSE RATE client in longterm, glucometer- EVALUATE CALIBRATION med prescribed on 3rd day, given on 4th- EVALUATE SIGNS OF OVERDOSE 4 postop clients with drainage- 40ML DARK CLOUDY URINE staff nurse tardy- STRESS IMPORTANCE OF BEING ON TIME! client to be assessed first- PT IN RESTRAINTS FOR 6 HRS! post-op wound infection- TRANSFER CLIENT WITH NEURTROPENIA TO PRIVATE ROOM home health pt with als- FEEDING CLIENT A MEAL client with bacterial meningitis- INCREASING PULSE PRESSURE metastic lung cancer- ENSURE SCRIPTS FOR TRANSFER INCLUDE END OF LIFE CARE client on morphine already took it from home- ADMINISTER MED AT PRESCRIBED TIME WHEN FAMILY SAID 32 yr old diagnosed with aids, who goes with client?- 19 YEAR OLD WITH KARPOSI SARCOMA fire! - EVACUATE AMBULATORY PT’S FIRST! 20 units of 70/30 insulin- NOTIFY PHARMACY INCORRECT DOSE WAS GIVEN 6 concern about physician procedures- REPORT PHYSICIAN! picture of gastronomy tube- STOP MED ADMINISTRATION budget cuts- TAKE NURSE TO PRIVATE ROOM narcan question- WHEN TO CALL HCP which should be assigned to the rn?- BILATERAL AKA NOW HAS A SACRAL DECUBITUS SKIN FLAP receiving end of life home care, pt is cachexic- ONLY ABLE TO TAKE SIPS pn tell nuse doesn’t want to do procedure- TELL PN ASSISTANCE IS AVAILABLE BUT SHE IS RESPONSIBLE FOR CARE orientee overwhelmed, beem out of work 10 years- ASSIGN ORIENTEE TO WORK WITH EXPERIENCED NURSE discharged from ambulating after varicose vein stripping teaching- ELEVATE FOOT OF BED WHILE IN BED 100. asa scheduled at 0900, complaints of pain at 0800- OBTAIN PRESCRIPTION FOR PRN ANALGESIC 101. reading back hcp prescription, most important to implement- INITIATE TELEMETRY & OBTAIN CARDIAC RHYTHM 102. peripheral infusion site of a blood transfusion- ECCHYMOTIC…SWOLLEN 103. – ASK COWORKER TO RESPOND TO THE CLIENT WHOSE CALL BELL IS RINGING HESI Leadership/Management Finding a client sitting on the floor, nurse calls for help from UAP Get a BP cuff Assigning a UAP to assist client with personal care Prescribed activity level The ICU is full and short staffed, so nursing super informs charge nurse in the med dept that one nurse must float to the ICU Staff nurse who was cross-trained to work in the critical care dept Charge nurse developing guidelines for a coronary care unit The scope of standards of practice from the American nurses association Which patient should be assigned to a nurse that is floated from maternity unit Post op hysterectomy There has been a major disaster. Triage nurse should give which patient priority Cut over eye Delegate to LPN Dressing change Move which patient to medical surgical unit Patient with ABNL liver levels One open bed in ICU but reserved for patient coming from PACU with respiratory problems, what to do Take patient to ICU and arrange for respiratory patient to stay in PACU UAP giving complete bath-which patient is more concern Patient with dyspnea (SOB when lying flat) ER nurse getting moved to L&D, what patient should leader assign Patient with episiotomy infection DNR Notify the family Against medical Advice (AMA)with and IV RN removes IV, sign the document AMA form Prescriptions-telephone repeat order back to doctor to make sure it is correct Assign UAP hygiene, feeding, ADLS, ROM, ambulation Confidentiality-emergency department don’t give out information about patient, don’t talk about patients condition in front of people, keep records safe Malpractice negligence by professional personnel Ex: buring client with hot heating pad, ignoring s/s of bleeding, giving wrong medication Patient bill of rights show pt there bill of rights, they have the right to see their chart and anything regarding their care Assign PN-scope of practice No assessments, teaching (newly DX'd), IV's, blood transfusions, no suicide patients, no critical patients Assignments-new grad graduate nurse supervised by RN, what pt to give? Infusing antibiotic or choosing catheter port Unsafe nurse after nurse goes through rehab she can do her job regularly Brain death-organ donation if person is organ donor and is brain dead, organs can be donated Critical lab value high levels or low levels (know levels) potassium is a priority lab value Fibromyalgia assistance provide uninterrupted sleep and refer to pain specialist RN role-assess RN’s assess not LPN or UAP Med error- action assess pt, incident report, notify doctor, document amt prescribed, and dosage given MRSA room assigned private room, contact isolation Restraints standards of care Cultural Native American POC Know rules for Immunization permission Priority care Management Ethical Assign least care to UAP Consent to treat without consent Know Lack of fidelity Know Role ambiguity Pt having sex in hospital room Close the door Clients rights to give Informed consent is based on which ethical principle Autonomy Conflict resolution-nurses Ask the nurses to meet with the nurse manager to identify ways of working CPR Evaluate effectiveness Delegation-PN An elderly client with Alzheimer’s disease complicated by dysphagia (assign to LPN) Pain management issue Teach patient how to use PCA Know how to utilize time management NGT Irrigation-assignment RN must irrigate UAP using a hand sanitzers that is alcohol for 2 minutes tell that hand sanitizer use is less > 2min charge nurse developing the nursing guidelines for a coronary care unit The Scope of Standards of Practice from the American Nurses Association nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget Operating budget nurse has not finished administering routine oral medication because one pt experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding reporting blood glucose results to the nurse the LPN says the glucometer was not calibrated prior to use because the report given by the night shift staff ran late Advise the LPN of the implications involved by not calibrating the glucometer Risk management: pt fell while using some equipment charge nurse trying to find out what happened- hospital polices New RN to Unit best client to assign is client 4 days post MI Incorrect Delegation LVN/LPN to remove staples from abdominal wound Client in labor, you call the provider and he has slurred words, loud noise in background, and seems intoxicated contact the healthcare provider’s associate, not the medical director What source states the legal requirements nurses must follow to protect client confidentiality in a nurse- patient relationship State Nurse Practice Acts nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions A 35-year-old with lupus erythematosus female with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chonic pain- interdisciplinary team member Pain specialist What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP) Evaluate the experience of the UAP Nurse writes on the chart that another nurse did not take great care of a patient Libel nurse behavior is a breach of clients confidentiality according to the Health Insurance Portable Accountability Act (HIPAA) regulations Take home a daily report sheet with the information of the team’s client male with cancer admitted to the oncology unit tells the nurse that he is in the hospital for palliative care measures but ordered prescriptions include radiation therapy Consult with the client about his expected goals for his hospitalization and current treatment plan on a surgical unit nurse receives a personal phone call about a family emergency that requires the nurse to leave immediately Notify the charge nurse of the situation and of the need and leave immediately If you see a nurse make a mistake-Chain of command speak to her before going to management. If the situation persists, then take it higher LVN/LPN cant Handle any blood HESI LEADERSHIP When entering a client's room to administer a 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement? ~ Leave the room and closed the door quietly When triaging emergency-room clients, which client should the nurse assess first? ~ A female client with severe right lower abdominal pain who is febrile and vomiting. During a woman's health fair, which assignment is best for the practical nurse who is working with a registered nurse? ~ Prepare a woman for a bone density screening A mental health nurses admitting a female adolescent who is accompanied by her mother and father. The nurse received report from the emergency department at the client has a medical diagnosis of depression and has attempted to harm herself. Which task should the nurse assigned to the mental health technician? ~ Search all of the clients belongings The nurse assigns collection of the sputum specimen to an unlicensed assistive personnel. Before delegating this task to the UAP, which action is most important for the nurse to implement? ~ Determines if the UAP has received training to collect sputum specimen When meeting with the client and the family, which nursing interventions demonstrates the nurse role of collaborator of care? ~ Coordinating and educating about multidisciplinary services Based on the change of shift report, the client with which signs and symptoms should be assessed by the nurse first? ~ Chest pressure….yup, diaphoresis, nausea The nurse working on a medical unit is assigned to care for four clients. Which client should the nurse assess first? ~ A client who is quadriplegic and is complaining of severe headache Which action by the nurse-manager demonstrates an effective leadership style? ~ Fosters positive behavior changes in staf f numbers Female client complains to the charge nurse that the unlicensed assistive personnel did not close the window shades to a public sidewalk while giving him a bath earlier in the morning. Which action should the charge nurse take? ~ Apologize to the client immediately The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? ~ A client scheduled for a femoro-popliteal bypass surgery tomorrow The charge nurse of the intensive care unit is making assignments for the permanent staff and Juan are in who has floated from a medical unit. The client with which condition is best to assign to the float nurse? ~ Emphysema extubated three hours ago receiving heated best The charge nurse agrees to cover another nurses assignments during lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client: ~ With a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% During a staff meeting, the nurse verbally attacks the nurse-manager conducting the meeting stating, you always let your favorites have holidays off and give them easier assignments. You are unfair and prejudice. How should the nurse-manager response? ~ I would prefer to discuss t his with you privately Following a six-week refresher course, the female nurse who has been out of the workforce for 10 years is assigned to the medical unit for orientation. After the first week of orientation the charge nurse notes that the she is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take? ~ Assign the orientee to work with a practical nurse who is a long time, efficient employ A client was amended during the night for a postoperative wound infection and wa s signed to a semi private room with a client who has lung cancer and is neutropenic. At morning report the nurse learns that the wound infection is positive for methicillin-resistant Staphylococcus aureus MRSA. Which intervention should the nurse implement? ~ Transfer the client with neutropenia to a private room The charge nurse of a 24-bit medical unit is making shift assignments to 2 experienced RN's, 1 graduate are in, 1 LPN, and 2 UAP's. Which client should the nurse assigned to the most experienced RN? ~ A 36-year-old admitted with angina who has a history of coronary artery disease A nurses doing telephone triage20at the clinic office. Which client is most acute and should be scheduled for the first available appointment? ~ A 21-year-old with a history of kidney transplant. Today the client complains of flu-like symptoms with a fever of 100.4°F Aspirin ASA 81 mg 9 AM daily is prescribed for the ball client. At 8: ~00 AM the client and ask for something for low back pain, but does not have any PRN analgesics prescribed. What action is best for the nurse to take? ~ Obtain a prescription for a PRN analgesic While the registered nurse is appearing to take the vitals signs of a newly admitted client who has a medical diagnosis of congestive heart failure, a practical nurse enters the clients roam and reports to the RN that another client just pulled out his central venous catheter and the unlicensed assistive personnel is in the room with the client. RN knows that the newly admitted client is to receive a stat dose of oral anti-anxiety medications. How should the RN assigned to the needed care? ~ RN should provide care for the client who removed the central venous catheter while PN administers a stat medication and the UAP obtained the newly amended client's vital signs 21. The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision? ~ The acuity level of the client's on the unit 22. While supervising a client who was performing self-catheterization, the nurse is paged to receive the telephone report on a postoperative client who must be transferred immediately. How should the nurse respond? ~ Ask the charge nurse to take the report while the client finishes the procedure. 23. The RN is assigned to care for 4 surgical clients. After receiving report, which client should the nurse see first? ~ The client who is: ~ three days postoperative: ~ resection receiving transfusion of packed RBCs 24. After receiving report, which client should the nurse assess first? ~ A client with an oxygen saturation of 70% following bronchodilator therapy 25. A fire is reported in the kitchen on the first floor of a three-floor community Hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. What intervention should the charge nurse implement? ~ Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits 26. A staff member who sometimes has red swollen eyes and has been increasingly irritable during the past month, arrives for work smelling of alcohol. What initial action should the nurse - manager take? ~ Confront the staff member in private about the smell of alcohol 27. The nurses caring for several clients on the telemetry unit. Which client should the nurse assess first? ~ A client who is demonstrating: ~ normal sinus rhythm and complaining of chest pain 28. The charge nurse is making assignments for a 15 bed skilled nursing unit with the staff of one RN, two LPN, and two UAP's. Which client should be assigned to the RN? ~ A client who: ~ had bilateral above knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin IV 29. An unlicensed assistive personnel UAP who is working on a skilled nursing unit is diagnosed with hepatitis A HVA. Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, low- grade fever. What action should the nurse - manager take next? ~ Referral the nurse to employee health for serological testing 30. A nurse preceptor is teaching a graduate nurse about the effective time management. Why should the nurse preceptor focus on first? ~ Approaches to prioritizing care 31. A practical nurse PN is reluctant to use new blood glucose monitoring equipment despite having attended the mandatory in-service about the equipment. What action is best for the charge nurse to take? ~ Observe the PN while he uses the new equipment 32. A32-year-old male client diagnosed with AIDS must be assigned to a semi-private room. Which roommates should the charge nurse place with this client? ~ A19-year-old with Kaposi’s sarcoma 33. To facilitate the suspects of a new fall prevention program, which action should the nurse manager implement? ~ Involve the staff in developing interventions for the program 34. A nurse - manager observes that a staff nurse does not know how to perform many client care skills, is unable to complete assignments in a timely manner, and often persuades a former classmate to complete assignments. How should the nurse - manager respond to this situation? ~ Meet with the staff nurse and implement a written contract for performance improvement 35. Which statement best describes managed care that is implemented by the specific health care delivery agency? ~ Each20member of the health care team performs specific tasks for client care to ensure implementation of a client's critical pathway 36. The nurses supervising a home health aide performing care for a client with end-stage amyotrophic lateral sclerosis ALS. It is most important for the nurse to observe which task? ~ Feeding the client a meal 37. At 2 a.m. the nurse phones the health-care provider to request a PRN medication for a client who is unable to sleep. The health-care provider is awakened, and gives the nurse a prescription for 4 times the normal dosage. When questioned by the nurse, the health-care provider responds in a sleepy voice. Yeah okay and hangs up the phone. What action should the nurse take first? ~ Call the health-care provider pack, and report that the dosage described is 4 times the normal dose 38. The nurses conducting a retrospective c hart audit to investigate whether outcomes recorded in each nursing care plan are client centered in Redden and behavioral terms. The continuous quality improvement committee expected benchmark is 98% compliance. The sample size is 200 charts, and the results show 100 charts meet the benchmark. Which evaluation outcome should the nurse conclude? ~ The benchmark was not met and an action plan should be developed 39. A newly hired unlicensed assisted personnel expresses fear to the charge nurse about collecting a sputum specimen for a client who is HIV-positive. What action should the charge nurse take first? ~ Determine the UAP's knowledge about HIV transmission 40. A client in the intensive care unit needs to be transferred to the medical unit to make room for a client who is being admitted from the emergency department. Which client is best for the charge nurse to transfer? ~ A client with: ~ chronic emphysema who has an arterial blood gas PaO2 of 75 41. The practical nurse caring for a client with acute congestive heart failure and pitting edema tells the charge nurse that a verbal prescription was obtained from the health-care provider for 1000 mL D5 ½ normal saline to be administered over a 4 hours. What action should the charge nurse take? ~ Clarify the prescription with the health-care provider 42. The nurse should assess the client with which problem first? ~ Paresthesia secondary to an arterial occlusion 43. Which client is best to assigned to the LP and who is assisting the RN with care of a group of clients? ~ A client who: ~ had laproscopic cholecystectomy the previous day 44. After receiving morning report on an acute care unit, which client should the nurse assess first? ~ A client sitting close to the nurses station who has been restrained for the past six hours 45. The registered nurse is gathering supplies to assist a health-care provider with a bedside thorocentesis when the emergency department nurse calls to report on a client with unstable angina that must be admitted immediately. A practical nurse and unlicensed assisted personnel are available to assist the RN. How should the RN assigning the necessary nursing action? ~ Assign the PN to assist with the thorocentesis while the nurse obtains report in the UAP prepares the ro om for the new admission. 46. To help prevent litigation by the dissatisfied client, which objectively is most important to include in the orientation classes for staff nurses? ~ New nursing staff members will: ~ discuss how to handle complaints from the client and/or their families 47. A client has a prescription for 20 units of Novolin 70/30 insulin to be administered subcutaneously. The pharmacy has provided a vial of Novolin N insulin in a vial of Novolin R insulin. What action should the nurse implement? ~ Notify the pharmacy that the incorrect insulin has been delivered to the unit 48. The unlicensed assisted personnel assigned to attain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beats/minute. What action should the charge nurse implement? ~ Assign a practical nurse to determine if in a local radial deficit is present 49. A female student nurse is paired with a staff nurse as a learning experience. The student nurse has an offensive body odor, her uniform is wrinkled, and she is acting sluggish and tired. What action should the staff nurse implement? ~ Ask the student to wait into the lounge until her faculty member is contacted 50. The nurse watches an unlicensed assisted personnel bring soap, wash cloth and towels, and a basin into the room of a male client who has a suprapubic catheter inserted the previous day. What action should the nurse implement? ~ Tell the UAP that the nurse will perform the client's catheter care after the UAP assist with his personal care 51. After receiving report on an inpatient acute care unit, which client should the nurse assess first? ~ A client: ~ with a bowel obstruction due to a valvulas who is experiencing abdominal rigidity 52. The nurses caring for a group of clients on a surgical unit. What action should the nurse implement first? ~Determine if the client scheduled for surgery is prepared to go to the operating room 53. In assigning client care to an RN and a licensed practical nurse, it is most important to assigned which client to the RN? ~ A client who: ~is exhibiting signs of Addison's crisis after corticosteroids were discontinued 54. After reviewing the morning laboratory findings for 4 clients, which client should the nurse follow- up with first? ~The BNP assay for a client with shortness of breath after a MI increases to 1000 pg/ml. 55. Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel informs the nurse that one of the visitors is lying on the client’s bed. What action should the nurse implement? ~ Explained that the client has the right to have a visitor lie on the bed Leadership HESI, V.2 When entering a client's room to administer a 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement? ~ Leave the room and closed the door quietly When triaging emergency-room clients, which client should the nurse assess first? ~ A female client with severe RL abdominal pain who is febrile and vomiting. During a woman's health fair, which assignment is best for the practical nurse who is working with a registered nurse? ~Prepare a woman for a bone density screening…..thus this is what you will assign for an LPN A mental health nurses admitting a female adolescent who is accompanied by her mother and father. The nurse received report from the emergency department at the client has a medical diagnosis of depression and has attempted to harm herself. Which task should the nurse assigned to the mental health technician? ~ Search all of the client’s belongings The nurse assigns collection of the sputum specimen to an unlicensed assistive personnel. Before delegating this task to the UAP, which action is most important for the nurse to implement? ~ Determines if the UAP has received training to collect sputum specimen When meeting with the client and the family, which nursing interventions demonstrates the nurse’s role of collaborator of care? ~Coordinating and educating about multidisciplinary services Based on the change of shift report, the client with which signs and symptoms should be assessed by the nurse first? ~Chest pressure, diaphoresis, nausea The nurse working on a medical unit is assigned to care for four clients. Which client should the nurse assess first? ~ A client who is quadriplegic and is complaining of severe headache Which action by the nurse-manager demonstrates an effective leadership style? ~ Fosters positive behavior changes in staff numbers Female client complains to the charge nurse that the unlicensed assistive personnel did not close the window shades to a public sidewalk while giving him a bath earlier in the morning. Which action should the charge nurse take? ~ Apologize to the client immediately The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? ~ A client scheduled for a femoro-popliteal bypass surgery tomorrow The charge nurse of the intensive care unit is making assignments for the permanent staff and Juan are in who has floated from a medical unit. The client with which condition is best to assign to the float nurse? ~ Emphysema extubated three hours ago receiving heated best The charge nurse agrees to cover another nurses assignments during lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? ~ The client: ~ with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% During a staff meeting, the nurse verbally attacks the nurse-manager conducting the meeting stating, you always let your favorites have holidays off and give them easier assignments. You are unfair and prejudice. How should the nurse-manager response? ~ I would prefer to discuss t his with you privately Following a six-week refresher course, the female nurse who has been out of the workforce for 10 years is assigned to the medical unit for orientation. After the first week of orientation the charge nurse notes that the she is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take? ~ Assign the orientee to work with a practical nurse who is a long time, efficient employ A client was amended during the night for a postoperative wound infection and wa s signed to a semi private room with a client who has lung cancer and is neutropenic. At morning report the nurse learns that the wound infection is positive for methicillin-resistant Staphylococcus aureus MRSA. Which intervention should the nurse implement? ~ Transfer the client with neutropenia to a private room The charge nurse of a 24-bit medical unit is making shift assignments to 2 experienced RN's, 1 graduate RN, 1 LPN, and 2 UAP's. Which client should the nurse assigned to the most experienced RN? ~ A 36-year-old admitted with angina who has a history of coronary artery disease A nurses doing telephone triage20at the clinic office. Which client is most acute and should be scheduled for the first available appointment? ~ A 21-year-old with a history of kidney transplant. Today the client complains of flu-like symptoms with a fever of 100.4°F Aspirin ASA 81 mg 9 AM daily is prescribed for the ball client. At 8: ~00 AM the client and ask for something for low back pain, but does not have any PRN analgesics prescribed. What action is best for the nurse to take? ~ Obtain a prescription for a PRN analgesic While the registered nurse is appearing to take the vitals signs of a newly admitted client who has a medical diagnosis of congestive heart failure, a practical nurse enters the clients roam and reports to the RN that another client just pulled out his central venous catheter and the unlicensed assistive personnel is in the room with the client. RN knows that the newly admitted client is to receive a stat dose of oral anti-anxiety medications. How should the RN assigned to the needed care? ~ RN should provide care for the client who removed the central venous catheter while PN administers a stat medication and the UAP obtained the newly amended client's vital signs The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision? ~ The acuity level of the client's on the unit While supervising a client who was performing self-catheterization, the nurse is paged to receive the telephone report on a postoperative client who must be transferred immediately. How should the nurse respond? ~ Ask the charge nurse to take the report while the client finishes the procedure. The RN is assigned to care for 4 surgical clients. After receiving report, which client should the nurse see first? ~ The client who is: ~ three days postoperative: ~ resection receiving transfusion of packed RBCs After receiving report, which client should the nurse assess first? ~ A client with an oxygen saturation of 70% following bronchioilator therapy A fire is reported in the kitchen on the first floor of a three-floor community Hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. What intervention should the charge nurse implement? ~ Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits A staff member who sometimes has red swollen eyes and has been increasingly irritable during the past month, arrives for work smelling of alcohol. What initial action should the nurse - manager take? ~ Confront the staff member in private about the smell of alcohol The nurses caring for several clients on the telemetry unit. Which client should the nurse assess first? ~ A client who is demonstrating: ~ normal sinus rhythm and complaining of chest pain The charge nurse is making assignments for a 15 bed skilled nursing unit with the staff of one RN, two LPN, and two UAP's. Which client should be assigned to the RN? ~ A client who: ~ had bilateral above knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin IV An unlicensed assistive personnel UAP who is working on a skilled nursing unit is diagnosed with hepatitis A HVA. Two weeks later, a nurse complains of headache, nausea, anorexia, arthralgia, low- grade fever. What action should the nurse - manager take next? ~ Referral the nurse to employee health for serological testing A nurse preceptor is teaching a graduate nurse about the effective time management. Why should the nurse preceptor focus on first? ~ Approaches to prioritizing care A practical nurse PN is reluctant to use new blood glucose monitoring equipment despite having attended the mandatory in-service about the equipment. What action is best for the charge nurse to take? ~ Observe the PN while he uses the new equipment A32-year-old male client diagnosed with AIDS must be assigned to a semi-private room. Which roommates should the charge nurse place with this client? ~ A19-year-old with Kaposi’s sarcoma To facilitate the suspects of a new fall prevention program, which action should the nurse manager implement? ~ Involve the staff in developing interventions for the program A nurse - manager observes that a staff nurse does not know how to perform many client care skills, is unable to complete assignments in a timely manner, and often persuades a former classmate to complete assignments. How should the nurse - manager respond to this situation? ~ Meet with the staff nurse and implement a written contract for performance improvement Which statement best describes managed care that is implemented by the specific health care delivery agency? ~ Each20member of the health care team performs specific tasks for client care to ensure implementation of a client's critical pathway The nurses supervising a home health aide performing care for a client with end-stage amyotrophic lateral sclerosis ALS. It is most important for the nurse to observe which task? ~ Feeding the client a meal At 2 a.m. the nurse phones the health-care provider to request a PRN medication for a client who is unable to sleep. The health-care provider is awakened, and gives the nurse a prescription for 4 times the normal dosage. When questioned by the nurse, the health-care provider responds in a sleepy voice. Yeah okay and hangs up the phone. What action should the nurse take first? ~ Call the health-care provider back, and report that the dosage described is 4 times the normal dose The nurses conducting a retrospective c hart audit to investigate whether outcomes recorded in each nursing care plan are client centered in Redden and behavioral terms. The continuous quality improvement committee expected benchmark is 98% compliance. The sample size is 200 charts, and the results show 100 charts meet the benchmark. Which evaluation outcome should the nurse conclude? ~ The benchmark was not met and an action plan should be developed A newly hired unlicensed assisted personnel expresses fear to the charge nurse about collecting a sputum specimen for a client who is HIV-positive. What action should the charge nurse take first? ~ Determine the UAP's knowledge about HIV transmission A client in the intensive care unit needs to be transferred to the medical unit to make room for a client who is being admitted from the emergency department. Which client is best for the charge nurse to transfer? ~ A client with: ~ chronic emphysema who has an arterial blood gas PaO2 of 75 The practical nurse caring for a client with acute congestive heart failure and pitting edema tells the charge nurse that a verbal prescription was obtained from the health-care provider for 1000 mL D5 ½ normal saline to be administered over a 4 hours. What action should the charge nurse take? ~ Clarify the prescription with the health-care provider The nurse should assess the client with which problem first? ~ Paresthesia secondary to an arterial occlusion Which client is best to assigned to the LP and who is assisting the RN with care of a group of clients? ~ A client who: ~ had laparoscopic cholecystectomy the previous day After receiving morning report on an acute care unit, which client should the nurse assess first? ~ A client sitting close to the nurses station who has been restrained for the past six hours The registered nurse is gathering supplies to assist a health-care provider with a bedside thorocentesis when the emergency department nurse calls to report on a client with unstable angina that must be admitted immediately. A practical nurse and unlicensed assisted personnel are available to assist the RN. How should the RN assigning the necessary nursing action? ~ Assign the PN to assist with the thorocentesis while the nurse obtains report in the UAP prepares the room for the new admission. To help prevent litigation by the dissatisfied client, which objectively is most important to include in the orientation classes for staff nurses? ~ New nursing staff members will: ~ discuss how to handle complaints from the client and/or their families A client has a prescription for 20 units of Novolin 70/30 insulin to be administered subcutaneously. The pharmacy has provided a vial of Novolin N insulin in a vial of Novolin R insulin. What action should the nurse implement? ~ Notify the pharmacy that the incorrect insulin has been delivered to the unit The unlicensed assisted personnel assigned to attain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beats/minute. What action should the charge nurse implement? ~ Assign a practical nurse to determine if a local radial deficit is present A female student nurse is paired with a staff nurse as a learning experience. The student nurse has an offensive body odor, her uniform is wrinkled, and she is acting sluggish and tired. What action should the staff nurse implement? ~ Ask the student to wait into the lounge until her faculty member is contacted The nurse watches and unlicensed assisted personnel bring soap, wash cloth and towels, and a basin into the room of a male client who has a suprapubic catheter inserted the previous day. What action should the nurse implement? ~ Tell the UAP that the nurse will perform the client's catheter care after the UAP assist with his personal care After receiving report on an inpatient acute care unit, which client should the nurse assess first? ~ A client: ~ with a bowel obstruction due to a valvulas who is experiencing abdominal rigidity The nurses caring for a group of clients on a surgical unit. What action should the nurse implement first? ~ Determine if the client scheduled for surgery is prepared to go to the operating room In assigning client care to an RN and a licensed practical nurse, it is most important to assigned which client to the RN? ~ A client who: ~ is exhibiting signs of Addison's crisis after corticosteroids were discontinued After reviewing the morning laboratory findings for 4 clients, which client should the nurse follow-up with first? ~ The BNP assay for a client with shortness of breath after a MI increases to 1000 pg/ml. Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel informs the nurse that one of the visitors is lying on the client bed. What action should the nurse implement? ~ Explained that the client has the right to have a visitor lie on the bed HESI LEADERSHIP (Correct Answer given in the last page) 1 A charge nurse for the emergency department is supervising a nurse who has been temporarily reassigned from the medical-surgical unit during a b usy time. Which of the following assignments is most appropriate for this nurse? Obtaining a medical history from a client who attempted suicide Collecting a catheter urine specimen from a 2-year-old child with a fever Setting up a trauma room for an incoming motor-vehicle crash victim Performing triage for three clients who have just arrived in the waiting ar ea 2 A nurse should first provide care for which of the following clients? An older adult with dyspnea and a respiratory rate of 22/min A toddler who has a head laceration oozing dark red blood An adult client with large ecchymoses on both legs An adolescent with an injured ankle and pain rated at 10 on a 0-10 scale 3 A client with methicillin-resistant Staphylococcus aureus (MRSA) of the urine is being admitted into the hospital and is placed on contact isolation . Which of the following should cause the charge nurse to intervene? The client is dressed in an isolation gown for transport to x-ray. The door for the isolation room is left open. A nurse checks the client's IV without wearing gloves. A provider uses alcohol-based hand cleanser after providing care. 4 A nurse is caring for a competent client who is newly diagnosed with a t erminal illness. Which of the following statements by the client indicates a correct understanding of advance directives? "From this point on, my partner has control over my health care decisions ." "I am so relieved that the decisions about my care are finalized." "I'm glad that the doctors now can make all the final decisions." "When I can no longer make decisions, people now know what I want." 5 A client who is intoxicated presents to the emergency department and repo rts struggling with depression lately. The next day, the client is ready for discharge and states, “It’s okay. Soon everything will be just fine.” Which o f the following is the nurse's priority action? Ask the client if he is feeling suicidal. Remind the client that change is always possible. Inquire about the client's regular alcohol consumption. Reinforce the need to follow up with the discharge referral. 6 A client diagnosed with an inferior MI 2 days ago suddenly reports nause a and midsternal chest pain. After ensuring that oxygen support is patent, w hich of the following interventions should the nurse anticipate taking next? Assess for S3 heart sounds. Administer a prescribed antiemetic. Notify the primary care provider. Obtain a 12-lead ECG. 7 The staff on an orthopedic unit have implemented a plan to prevent loss of revenue from supply and equipment charges. Which of the following indic ates that the plan is successful? Supplies for dressing changes are kept at the bedside. Billing for the unit has increased in the last quarter. Unused supplies from discharged clients are saved for future use. Documentation of the supplies used for each client is complete. 8 A nurse working in an emergency department has been assigned four clien ts. Which of the following client conditions should be reported to the appr opriate authorities? A female client with deep bruising to her lower leg An adolescent client with Clostridium difficile An older adult client with a stage I pressure ulcer A male client with a bite from an unknown dog 9 A nurse is caring for an older adult client with type 1 diabetes mellitus and a stage II ulcer on his left leg. The client’s medical history indicates t hat he drinks a pint or two of vodka each day. Which of the following should t he nurse include in the client’s plan of care? Coordinate a referral to an outpatient alcohol treatment center. Involve the family in confronting the client about his alcoholism. Teach the family how to monitor and control the client’s alcohol intake. Provide strategies to assist the client in moderating his alcohol intake. 10 A nurse is assigned a non-English speaking client who is scheduled for surgery. Which of the following is the appropriate method for obtaining inf ormed consent from the client? Use a professional interpreter. Request that a family member act as a translator. Ask a bilingual nurse on the unit to assist the client. Provide the consent document in the client's native language. 11 When planning for updates on infection control, fire and safety, and con fidentiality issues, which of the following methods of educational delivery is most efficient? Classes available monthly by the staff development educators Day-long training sessions available twice a year Each unit providing classes at shift changes Self-directed computer-based modules with posttests 12 A charge nurse is assessing staff knowledge about safety procedures reg arding needle stick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? "Prophylactic treatment should be initiated after a needle stick during pre paration of an injection." "I should stop the bleeding as soon as possible following a needle stick in jury." "An incident report should be completed if a client receives a stick from her own used needle." "The needle should be recapped to prevent injury during transport to the biohazard container." 13 A nurse at a long-term care facility is planning a fall prevention progra m for the residents. Which of the following should be included in the plan? Keep the four side rails up on beds at night. Apply vest restraints on residents who are confused. Accompany residents older than 85 during ambulation. Institute rounds every 2 hr during the day to offer toileting. 14 A nurse is providing discharge instructions to a client who had a mastec tomy and is going home with a drain. Which of the following statements is ap propriate to include in the instructions? "Begin performing stretching exercises the day after you get home." "Keep the incision dry until the stitches are removed." "Notify the primary care provider if there is numbness at the surgical site. " "Follow a low-sodium diet to prevent lymphedema." 15 A client is admitted to the hospital and makes end-of-life care decisions prior to the arrival of her family. The family arrives and asks the nurse to change the client's mind regarding end-of-life care. Which of the following actions should the nurse take? Facilitate a meeting with the client and the family. Have the family meet with the primary care provider. Request a social service consult for the client and family. Inform the family that the client's decisions are final. 16 A nurse who is caring for clients on the medical-surgical unit delegates collection of vital signs to an assistive personnel (AP). Which of the follow ing nursing actions is important in ensuring safe client care? The nurse looks at vital sign trends at the end of the shift. The nurse rechecks an abnormal blood pressure measurement. The nurse asks the AP to report any unusual findings. The nurse accompanies the AP during vital sign collection. 17 A nurse working in a rehabilitation facility is caring for a client with p araplegia from a spinal cord injury. An interdisciplinary team is scheduled to meet and discuss the client's needs. Which of the following concerns is the h ighest priority for the nurse to report to the team? The client has experienced a decrease in appetite. The client lives alone in a second-story apartment. The client has a stage I pressure ulcer on his heel. The client reports fatigue during occupational therapy. 18 An RN is planning client assignments for an assistive personnel (AP). T he RN should assign the AP to the care of a client who requires assessment of nasogastric tube output. feeding due to difficulty swallowing after a stroke. help with bathing and toileting following hip surgery. colostomy irrigations and bag changes. 19 A disaster is occurring, and the charge nurse on a medical-surgical uni t must determine which clients can be discharged. Which of the following cl ients should the nurse recommend for discharge? A client with a troponin level of 3 ng/mL A client with a deep vein thrombosis and an INR of 2.0 A client who is 1 day postoperative following gastrectomy A client who reports numbness on the left side of the face 20 A charge nurse suspects that a staff nurse has a problem with opioid abus e. Which of the following is the appropriate action for the nurse to take? Assign clients who are not prescribed opioids to the nurse. Collect data to support further action. Arrange for another nurse to witness the nurse administer opioids. Report the nurse to the state board of nursing. 21 An RN has just received report for four clients. The nurse should plan to first assess the client who has pain uncontrolled by PCA morphine. a newly discovered nonblanching reddened area on the right hip. a nonpatent gastric tube used for bolus feedings. refused to go for a scheduled gastrointestinal diagnostic procedure. 22 A nurse is preparing to witness the informed consent of a client who is to undergo a gastrectomy. The client has a question regarding the postoperat ive diet. Which of the following should the nurse do? Review the surgeon's instructions regarding the procedure. Reassure the client that there will be time to review the diet after surgery. Notify a registered dietician and have her explain the diet to the client. Answer the question and have the client sign the surgical permit. 23 On admission, a female client who is Muslim tells the female charge nur se that she wants only female nurses to provide her care. Which of the foll owing actions should the charge nurse take first? Consult with the nursing supervisor. Explain that clients are not allowed to pick caregivers. Explore the basis for this request with the client. Provide the client's care herself. 24 A triage nurse in an emergency department should assign priority to a cli ent arriving with a laceration of the right index finger with profuse bleeding. sudden onset of left-sided paralysis and slurred speech. severe vomiting and diarrhea with dehydration. a burn of the right lower forearm with significant edema and blistering. 25 A fire is discovered in the hospital, and the charge nurse has orders to evacuate. Which of the following clients should be evacuated first? A client who is in Buck's traction for a left hip fracture A client who is 1 day post thoracic surgery with a chest tube A client who is confused and restrained for safety A client who is ambulatory and receiving an infusion of chemotherapy 26 A client is brought to the emergency department (ED) following a motor- vehicle crash. Drug use is suspected in the crash, and a voided urine speci men is ordered. The client repeatedly refuses to provide the specimen. Whic h of the following is the appropriate action by the nurse? Document the client's refusal in the chart. Tell the client that a catheter will be inserted. Keep the client in the ED until a specimen is provided. Assess the client for urinary retention. 27 A primary care provider recommends surgery for a client with a tumor. T he client is refusing, but the spouse wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done? Whether the spouse is the client's durable power of attorney for health car e Whether the client's refusal is based on religious belief Whether the client understands the risk of refusing the procedure Whether the facility ethics committee reaches a consensus on the case 28 A nurse is teaching a client how to use a finger-stick glucometer at hom e. Which of the following instructions should the nurse include? Use an alcohol pad at the site after taking the sample. Cap the lancet prior to putting it in the trash. Obtain the sample from the finger pads. Warm the hands prior to taking the blood sample. 29 A nurse notes a new prescription in a client's medical record for oral d igoxin (Lanoxin) 2.5 mg to be given daily. The nurse questions the dosage of the prescription, and the provider confirms the dosage as written. Which of the following responses by the nurse is appropriate? Verify that the client's apical pulse is greater than 60/min. Check the client's serum digoxin and potassium levels. Hold the medication and contact the nursing supervisor. Request an order for telemetry monitoring. 30 A case manager is caring for an older adult client with type 1 diabetes m ellitus, chronic renal failure, and limited visual acuity. The client lives a lone and has children who visit infrequently. Which of the following should t he case manager recognize as the highest priority consideration? Nutritional resources Financial assistance Medication monitoring Housekeeping assistance 31 A nurse is caring for a client who sustained multiple injuries in a motor -vehicle crash, which was reported in the local newspaper. A newspaper report er calls for an update on the client's condition. The nurse tells the reporte r that the client has had surgery and is stable. The nurse has committed an a ct of slander. libel. willful neglect. invasion of privacy. 32 A charge nurse overhears an exchange between a client and a staff nurse. Which of the following statements by the staff nurse indicates a need for f urther education on client rights? "I can't discuss with you the medical care of the client in the next bed." "You shouldn't read your medical chart because you won't understand the terminology." "You cannot be transferred to your preferred facility until we are notified that there is space available." "I will request a list of the hospital's charges for services for you to revie w." 33 A nurse receives report on four clients. Which of the following clients sh ould the nurse attend to first? A client admitted this morning with unstable angina A client who vomited once at the end of the last shift A client who has an Hgb of 7 g/dL and an Hct of 26% A client who is currently trying to climb out of bed 34 A nurse on an orthopedic unit is assigned to work with a new assistive personnel (AP). The AP is delegated the task of transferring a client with a knee replacement from the bed to a chair. Which of the following is the m ost appropriate method of ensuring the new AP can perform the action safely? Teach proper technique for this skill to the AP. Ask the AP if he has prior experience with this skill. Review the AP's skills checklist. Watch the AP demonstrate the skill. 35 During discharge teaching, a nurse learns that a client does not have tr ansportation for a follow-up appointment with the primary care provider. Whi ch of the following is the most appropriate action by the nurse? Provide the client with information regarding public transportation. Refer the client to a social worker for transportation options. Call the primary care provider to reschedule the appointment. Encourage the client to seek transportation from family after discharge. 36 The husband and children of an older adult female client are expressing conflict over whether the client should receive surgery that is recommended by the primary care provider. The oldest son has durable power of attorney f or health care for both his mother and father. The client is oriented to per son, place, and time. Which of the following people has the legal authority to make this health care decision? The husband The oldest son The primary care provider The client 37 A nurse is caring for four clients. Which of the following tasks can be d elegated to an assistive personnel? Assessing a client who just returned from hemodialysis Reviewing dietary instructions for a client with kidney stones Obtaining a stool sample from a client with renal failure Monitoring a client with a fluid restriction 38 A charge nurse on a medical-surgical unit is responsible for supervising the care provided by the unit staff. Which of the following is the most effec tive method for determining the learning needs of the unit staff? Ask unit staff to complete a skills checklist. Require attendance at annual competency updates. Perform direct observation of provided care. Implement a peer review process on the unit. 39 A charge nurse notices that two staff nurses take no breaks during their regular 8-hr shifts. Which of the following should the charge nurse plan to d o? Give them overtime pay for the break times. Ensure coverage for enforced break times. Assign the two staff nurses the same break times. Allow them to take their breaks while charting. 40 A staff nurse reports for a regularly scheduled shift and finds that the un it is short of staff. The charge nurse insists that the nurse care for five cli ents who are high acuity despite the staff nurse's objections. Which of the fol lowing actions should the staff nurse take? Care for the five clients as best as possible. Delegate initial shift assessments to assistive personnel. Call nurses from the float pool to report to the unit. Notify the nurse manager of the situation. 41 A client with a draining foot ulcer is being prepared for discharge hom e with the family. The nurse observes another nurse changing the client's w ound dressing. Which of the following actions requires intervention to main tain safe handling of contaminated material? The old dressing is placed on a nearby table. Gloves are discarded after removing the old dressing. Sterile supplies are opened prior to the procedure. The wound is irrigated into a clean basin. 42 A nurse is assigned four clients. Which of the following client needs take s priority? A client’s intravenous site has infiltrated. A client’s capillary blood glucose is 250 mg/dL. A client reports a frontal headache rated at 7 out of 10. A client is refusing a scheduled nebulizer treatment. 43 A client had a cerebrovascular accident (stroke) 2 days ago. Which of th e following assessments should a nurse recognize as indicating a need for a referral to a speech and language pathologist? Altered level of consciousness Unilateral facial drooping Persistent coughing while drinking Left-sided hemiparesis 44 A nurse in an outpatient clinic is taking a medical history on a new cl ient. The client takes multiple medications each day but cannot remember th e names. Which of the following is the most appropriate response by the nur se? "What is the name and phone number of your primary doctor?" "You should make a list of all your medications for future use." "Next time you come to the clinic, bring the medications with you." "What conditions are you taking medications for?" 45 A nurse manager wants to implement a new safety program. Which of the following actions will best facilitate the program’s success? Indicate that the change is mandatory. Offer rewards to staff members who comply. Involve staff in planning its implementation. Tell staff to report problems to management. 46 A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? Plan break times for assistive personnel. Pick up the meal trays after lunch. Administer a nasogastric tube feeding. Determine adequacy of ventilator settings. 47 A new graduate nurse is taking a telephone medication order from a prima ry care provider and is having difficulty hearing the provider's prescriptio n. Which of the following is the most appropriate action by the nurse? Repeat the order back to the provider. Ask the charge nurse to take the order. Consult the pharmacist for clarification. Ask the provider to come write the order. 48 A nurse enters an adolescent’s room after some visiting classmates leave. The nurse notes a small fire in the client’s waste paper basket. Which of th e following is the nurse’s priority action? Use the client’s telephone to report the fire. Assist the client out of the area immediately. Cover the waste paper basket with a bedpan. Use the nearest fire extinguisher to put out the fire. 49 An older adult client with terminal cancer is brought to the emergency d epartment with acute pneumonia. The client has a valid living will that indi cates comfort measures only should be used. Which of the following is approp riate to include in the client's plan of care based on the living will? Titrate oxygen to maintain an oxygen saturation of 92%. Prepare the client for IV dopamine (Intropin) to maintain blood pressure. Administer oral chemotherapy to the client. Contact the immediate family for care-giving decisions. 50 A charge nurse notices that staff nurses are having difficulty using ne w IV pumps for medication administration. Which of the following actions by the charge nurse is most appropriate? Contact the staff education department for an in-service for the staff. Assume responsibility for IV medication administration during the shift. Instruct the staff nurses to administer IV medications without the pumps. Request assistance from the nursing supervisor. 51Which of the following actions taken by a nurse constitutes battery? Failing to put up side rails on a confused client's bed Telling a client who refused his oral medication that he will be given an i njection Inserting a feeding tube against the wishes of a client who refuses to eat Threatening to apply wrist restraints to control a client who is agitated 52 A visiting nurse is evaluating the home environment of an older adult c lient. Which of the following should the nurse recognize as an environmenta l hazard? The house has a short staircase covered with plush carpet. There is a household pet that wears a bell around its neck. Papers are scattered on the floor throughout the living room. The curtains in living areas are closed during the day. 53 A client states she will go home alone following her left hip pinning sur gery. The most appropriate action for the nurse to take is to chart the client’s comment in the medical record. contact the case manager for a consultation. call the primary care provider and report this information. use therapeutic communication to help the client verbalize her concerns. 54 A nurse finds a client lying on the floor of his hospital room. The clien t states that he slipped off the commode while trying to sit down. The client has no injuries and is stable upon assessment. After assisting the client ba ck to bed, which of the following should the nurse do? Restrain the client in bed. Complete an incident report. Administer a PRN sedative. Notify the risk manager. 55 A nurse is assigned to the care of four clients. Which of the following si tuations indicates the need for an interdisciplinary conference? A client with end-stage renal disease wants to die at home. A client states that he has just lost his job. A client indicates a desire to go home by taxi. A client relates difficulty getting up from the commode seat. 56 Which of the following tasks is appropriate for a nurse to delegate to an assistive personnel? Instruct a client who is in labor about breathing techniques. Measure oral intake for a client with dehydration. Inspect a preschooler for bruising and skin marks. Evaluate pain relief for a client who has received pain medication. 57 A nurse receives an order to transfer a client in the telemetry unit to the medical unit. After confirming bed availability on the receiving unit, which o f the following is the nurse's priority action? Call the family to inform them of the transfer. Provide client report to the receiving nurse. Contact the dietary department with transfer information. Inform the billing department of the client's change in status. 58 Which of the following puts a hospital at the highest risk for infringemen t of client record confidentiality? A nurse clusters documentation of care for multiple clients. A provider and nurse access client information using one access code. Paper-based charts are stored at the nurses' station. A nurse performs electronic documentation outside a client's room. 59 Two nurses are having a loud verbal discussion at the nurses' station abo ut not wanting to care for a client with drug-resistant tuberculosis. Which o f the following actions should the charge nurse take? Make arrangements to take over the client's care. Escort the nurses to the nurses' lounge to continue the discussion. Initiate disciplinary action for the nurses who are having the argument. Contact the house supervisor to mediate the conflict. 60 According to Health Insurance Portability and Accountability Act (HIPAA) regulations, which of the following is a violation of client confidentialit y? Calling in a prescription to a pharmacy for the spouse to pick up Providing a copy of the record to the transporting paramedic Reporting a client’s disposition to the referring primary care provider Informing housekeeping staff that the client is in the dialysis unit 61 A nurse is reading a chart at the nurses' station, and the unit clerk sud denly snatches the chart from the nurse. The unit clerk has a history of simi lar rude behavior when under stress. Which of the following should the nurse do? Report the unit clerk’s behavior to the nurse manager. Understand that the unit clerk's behavior is due to stress. Assume unit clerk responsibilities to avoid confrontation. Discuss the behavior with the unit clerk at the end of the shift. 62 A facility has identified an increase in nosocomial UTIs on the medical- surgical unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process? Develop a tool to track the ongoing incidence of UTIs. Analyze collected data on UTI incidence. Outline a goal of decreasing UTI incidence over the next year. Identify interventions to reduce the incidence of UTIs. 63 Which of the following items must be discarded in a biohazard waste rec eptacle? A urinary catheter drainage bag from a client who is postoperative A bedsheet from a client with bacterial pneumonia A peripad from a client who is 24-hr post vaginal delivery An empty IV bag removed from a client who has HIV 64 Which of the following statements made by a client who is in a clinical research study indicates proper understanding? “I’m in the study so I get the newest medicine.” “My participation will likely benefit others in the future.” “I will receive better care by being in the study.” “This is the best available treatment for my condition.” 65 A client who is being discharged requires home oxygen. The equipment company has not yet delivered the oxygen tank. The nurse should send a hospital oxygen tank home with the client. keep the client until the tank arrives. refer the issue to the home health care agency at discharge. give the equipment company's contact information to the client. Answer most correct. a few wrong 1) b 2) a 3) c 4) d 5) a 6) a 7) d 8) d 9) d 10) c 11) d 12) c 13) d 14) b 15) d 16) b 17) a 18) c 19) b 20) b 21) c 22) a 23) b 24) b 25) d 26) a 27) c 28) d 29) c 30) c 31) d 32) b 33) a 34) d 35) b 36) d 37) c 38) c 39) b 40) d 41) b 42) b 43) c 44) a 45) c 46) c 47) a 48) b 49) a 50) a 51) c 52) c 53) b 54) b 55) a 56) b 57) b 58) b 59) b 60) d 61) d 62) c 63) c 64) b 65) b HESI Leadership 1. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get better, I’m going to quit.” Which of the following responses by the unit manager is appropriate? a. You should file a written complaint with hospital administration b. Just stick with it a little longer. Things will get better soon c. So, you are upset about all the changes on the unit? d. I think you have a right to be upset. I am tired of the changes, too 2. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? a. Provide coverage for the nurses’ breaks b. Review facility policies for taking scheduled breaks c. Determine the reasons the nurses are not taking scheduled breaks d. Discuss time management strategies with the nurses 3. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include? a. Regular programming evaluations can be conducted by telephone b. The client should avoid using remote control devices to prevent dysrhythmias c. The client should avoid using a microwave oven to heat food d. Swimming could cause the unit to have an electrical short 4. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I will use an alcohol-based hand cleanser when caring for a client who has C.diff b. I will wear a cover gown when caring for a client who has herpes simplex c. I will wear an N95 respirator mask when caring for a client who is on contact precautions d. I will place a client who requires protective isolation in a negative airflow room 5. A staff nurse is supervising a newly licensed nurse who is preparing to administer an intermittent tube feeding to a client. Which of the following actions by the newly licensed nurseis appropriate? a. Adding colored food dye to the formula b. Flushing the tube with 15 mL of water c. Elevating the head of the bed to a 20-degree angle d. Checking residual volume before each feeding 6. A nurse is preparing an education program about professional codes of ethics for nurses. Which of the following information should the nurse plan to include? a. A code of ethics is a step-by-step approach to decision-making b. A code of ethics is a set of principles for nursing practice c. A code of ethics is legally binding d. A code of ethics outlines the nurse’s scope of practice 7. A nurse receives change-of-shift report for the following four clients. Which of the following clients should the nurse assess first? a. An older adult client who has bacterial pneumonia and a new onset of restlessness b. A client who is 1-day postoperative following hip fracture repair and reports a pain level of 6 on a scale from 0 to 10 c. A middle adult client who has diabetes mellitus and a morning blood glucose of 172 mg/dL d. A client who has myasthenia gravis with ptosis and has developed urinary incontinence 8. A charge nurse is assessing staff knowledge about safety procedures regarding needle-stick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures? a. Prophylactic treatment should be initiated after a needle-stick during preparation of an injection b. The needle should be recapped to prevent injury during transport to the biohazard container c. I should stop the bleeding as soon as possible following a needle-stick injury d. An incident report should be completed if a client receives a stick from her own used needle 9. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Libel b. Battery c. Slander d. Negligence 10. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first? a. Inform the unit manager of the incident b. Review the chart for nonrestraint alternatives for agitation c. Remove the restraints from the client’s wrists d. Speak with the AP about the incident 11. To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using? a. Compromising b. Collaborating c. Cooperating d. Competing 12. A nurse is caring for a client and notices fraying on the electrical cord of the client’s IV pump. Which of the following actions is the priority for the nurse to take? a. Remove the IV pump from the client’s room b. Check the expiration date of the inspection sticker c. Report the problem to the engineering team d. Request a replacement IV pump 13. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend? a. Pharmacist b. Child protective services c. Social worker d. Respiratory therapist 14. A charge nurse is completing client care assignments. Which of the following assignments is appropriate for a licensed practical nurse? a. A client who requires discharge instructions for type 1 diabetes mellitus b. A client who requires a blood transfusion to be administered c. A client who is 1 day postoperative and has a continuous bladder irrigation d. A client who is receiving IV chemotherapy 15. A nurse is caring for a client who is comatose and has advance directives designating his adult daughter as his health care proxy. The client’s partner instructs the nurse to institute CPRif the client experiences cardiac arrest. Which of the following actions should the nurse take? a. Have the partner notify the daughter about changes to the advance directives b. Inform the partner that the staff must follow the client’s advance directives c. Contact the client’s attorney about the partner’s request d. Initiate new advance directives incorporating the partner’s request 16. A nurse from the labor and delivery unit is assigned to float to a medical-surgical unit. Which of the following actions should the nurse take first? a. Inform the nursing supervisor of the lack of experience on the medical-surgical unit b. Request orientation to the medical-surgical unit c. Refer to the assigned resource nurse regarding client assignments d. Clarify competencies with the medical-surgical change nurse 17. A nurse in the emergency department is preparing a married 17-year-old client for an appendectomy. The client’s parents are en route to the facility but have not spoken with the surgeon. Which of the following actions should the nurse take? a. Have the client sign the consent form after the surgeon explains the procedure b. Obtain consent from the client’s parents by telephone with another nurse listening as a witness c. Proceed with the preparation because the client signed a general consent form d. Delay the surgery until the parents arrive to sign the consent form 18. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr postoperatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery? a. Pain assessment policy - check b. Postoperative care policy c. Prospective chart audit d. Retrospective chart audit 19. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the following statements by a staff nurse indicate understanding of the teaching? (Select all that apply.) a. I have the assistive personnel double-check packed RBCs when other nurses are busy b. I can delegate the removal of an IV catheter to an LPN on the unit c. I will attend continuing education classes for professional growth d. The family of a newly admitted client recently treated me to lunch in the hospital cafeteria e. I administer pain medication to my clients even if they have a history of narcotic addiction 20. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report? a. The time the client received his last dose of pain medication b. The belief that the client has a difficult relationship with his son c. The client’s preferred time for bathing d. The steps to follow when providing wound care 21. A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to assistive personnel? a. Performing a dressing change on a client’s peripherally inserted central catheter b. Instructing a client on self-administration of a tap water enema c. Using a pain rating scale to monitor a client’s pain level d. Suctioning a client’s long-term tracheostomy 22. A nurse on a medical-surgical unit is making staff assignments. Which of the following tasksshould the nurse delegate to assistive personnel? a. Pouching a client’s established ostomy b. Updating a family member about a client’s condition c. Reinforcing teaching with a client about a low-sodium diet d. Demonstrating the use of an incentive spirometer to a client 23. A charge nurse is reviewing how to set up a sterile field with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the process? a. I will open the outermost flap of the sterile tray towards my body b. I will place the sterile tray on a bedside table that is raised to just below my waist level c. I can touch the outer 2 inches of the sterile field without gloves d. I will keep the label of the solution bottle facing up when pouring solution into the sterile cup 24. A nurse is providing care for four postoperative clients. The nurse should first assess the client a. Who reports nausea after the prescribed antiemetic was administered b. Whose urine output has averaged 32 mL/hr for the past 24 hr c. Who reports a pain level of 8 on a scale of 0 to 10 d. Whose pulse has been steadily increasing during the past shift 25. A charge nurse overhears a provider and a nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first? a. Remind them that client information is confidential b. Report the incident to the nursing supervisor c. Complete an incident report about the situation d. Discuss the need for client confidentiality at the next staff meeting 26. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed? a. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client b. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min c. A nurse explains to a client’s family that a DNR order includes withholding comfort measures d. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better 27. The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision? a. The provider b. The partner c. The client d. The oldest adult child 28. A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take? a. Send an oxygen tank from the facility home with the client b. Instruct the client’s family to contact the insurance provider about the oxygen equipment c. Contact social services about the delivery of the oxygen equipment - check d. Notify the provider about the delayed oxygen tank delivery 29. A nurse in a long-term care facility is assessing a client who has returned from an acute care facility following a brief illness. The nurse observes that the client is confused and agitated. Which of the following actions should the nurse take first? a. Medicate the client with alprazolam b. Reorient the client to his surroundings c. Measure the client’s vital signs d. Offer reassurance to the family 30. A nurse is caring for a client who is scheduled for a procedure. Which of the following is an appropriate action when the nurse is witnessing the client signing the consent form? (Select all that apply.) a. Inform the client of available alternative therapies b. Discuss benefits of the procedure with the client c. Ensure the client gives consent voluntarily d. Verify that the client affirms understanding of the procedure e. Confirm the authenticity of the client’s signature 31. A nurse is documenting and completing an incident report after a client falls out of bed. Which of the following actions should the nurse take when completing the documentation? a. Document in nurse’s notes, “Photocopy of incident report sent to risk management” b. Document in incident report, “Client found lying on the floor after falling out of bed” c. Document in incident report, “Entered room and discovered client lying prone on the floor” d. Document in nurse’s notes, “Incident report completed and filed” 32. A nurse is providing discharge instructions to a client who is 2 hr postoperative following cataract surgery on the left eye. Which of the following instructions should the nurse include in the teaching? a. Sleep lying on your right side b. Bend at the waist if you must pick up an object from the floor c. Remove your eye shield before going to bed d. Place an ice pack on your left eye for 2 hours after you get home 33. A client is admitted with tuberculosis and placed in a negative-pressure room. Which of the following nursing actions is appropriate? a. Place a sign on the client’s door with the diagnosis b. Notify the local health department of the admission c. Determine who had contact with the client in the last 48 hr d. Ensure that admitting staff undergo PPD skin tests 34. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? a. Proceed with treatment without obtaining written consent b. Have the client sign a consent for treatment c. Notify risk management before initiating treatment d. Contact the client’s next of kin to obtain consent for treatment 35. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate? a. Why didn’t you discuss your concerns with your provider? b. If you have the procedure now, you won’t have to deal with pain and disability later c. You’ll be fine. You’ll receive a prescription for pain medication d. I understand, and it’s not too late to change your mind 36. A charge nurse is evaluating a newly licensed nurse’s understanding of infection control procedures. Which of the following actions demonstrates that the nurse is following the appropriate protocol for a client who has streptococcal pharyngitis? a. Placing the client in a positive-airflow room with 12 air exchanges per hour b. Explaining to the client that he cannot have visitors until his manifestations resolve c. Donning sterile gloves when performing routine oral care d. Wearing a mask when within 1 m (3.3 ft) of the client 37. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel? a. Informing a family of a client’s progress in physical therapy b. Teaching a client to perform a finger-stick for testing blood glucose levels c. Performing postmortem care prior to transferring the client to the morgue d. Advising a client on self-administration of acetaminophen 38. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change? a. Most recent blood glucose reading b. Laboratory tests scheduled for next shift c. Reddened area on the coccyx d. Glasgow Coma Scale score 39. A nurse in an urgent care clinic is admitting a client who has been exposed to a liquid chemical in an industrial setting. Which of the following actions should the nurse take first? a. Report the incident to OSHA b. Irrigate the exposed area with water c. Remove the client’s clothing d. Don personal protective equipment 40. A nurse is evaluating care for a group of clients. The nurse should consult the provider for which of the following clients? a. A client who requires an IV intermittent bolus dose of vancomycin and has a creatinine level of 1.5 mg/dL b. A client who is ready for discharge after coronary artery stent placement and has a prescription for clopldogrel c. A client who has a pacemaker and whose cardiac monitor shows sinus rhythm with intermittent periods of a wide QRS complex after each pacer spike d. A client who has atrial fibrillation and a rapid ventricular rate of 105/min and is receiving diltiazem IV and weight-based heparin 41. A nurse is planning care for four clients who were classified using a disaster triage tag system following a mass casualty event. Which of the following clients should the nurse identify as the priority? a. A client who has a green tag b. A client who has a black tag c. A client who has a red tag d. A client who has a yellow tag 42. A nurse is delegating tasks to assistive personnel (AP). Which of the following tasks shouldthe nurse assign to the AP? a. Instruct a client about the use of an incentive spirometer b. Check on a client whose telemetry monitor is continuously beeping c. Determine whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula d. Tag a malfunctioning piece of equipment as broken 43. A nurse is assessing a client who had a stroke 2 days ago. Which of the following findingsshould the nurse identify as a need for a referral to speech language pathology? a. Altered level of consciousness b. Impaired voluntary cough c. Diminished hand-to-mouth coordination d. Unilateral ptosis 44. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasingthe client’s risk for falls? (Select all that apply.) a. A two-wheeled walker used to assist the client with ambulation b. A folding chair without arm rests c. A throw rug covering some cracked vinyl flooring in the kitchen d. A wheeled office chair at the client’s computer desk e. A raised vinyl seat on the toilet in the bathroom 45. A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client’s room? a. Yankauer suction device b. Large-handled utensils c. Nasal cannula and oxygen d. Bite block 46. A nurse is comparing the rate of medication errors on the medical unit to the rate from a medical unit in a magnet hospital. Which of the following quality improvement methods is the nurse using? a. Risk benefit analysis b. Structure audit c. Benchmarking d. Root cause analysis 47. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the in-service? a. A nurse can disclose information to a family member with the client’s permission b. A nurse can apply restraints on a PRN basis c. A nurse is responsible for informing clients about treatment options d. A nurse can administer medications without consent to a client as part of a research study 48. A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department? a. Human papillomavirus b. Trichomoniasis c. Gonorrhea d. Candidiasis 49. A charge nurse is educating a group of newly licensed nurses about the case management approach to client care. Which of the following statements by a newly licensed nurse indicates an understanding of the responsibilities of a nurse in case management? a. Each nurse completes one specific task for a group of clients b. Nurses use critical pathways when caring for clients c. Nurses who have advanced training provide direct care for select clients d. Nurses delegate and supervise assigned tasks 50. A nurse is caring for a client who has signed consent for the removal of a tumor in the left frontal lobe of the brain. The client states, “The tumor is on the right side of my head.” Which of the following actions should the nurse take? a. Tell the client to mark the right side of his head with indelible ink b. Contact the surgery department to validate the operative site c. Continue with the surgery because the client already gave informed consent d. Ask the surgeon to clarify the operative site with the client 51. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot b. A client who is postoperative following a laminectomy 12 hr ago and is unable to void c. A client who has MRSA and has an axillary temperature of 38 C (101 F) d. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy 52. A nurse on a medical-surgical unit is preparing to assign vital sign measurements for a group of clients. Which of the following clients should the nurse delegate to assistive personnel? a. A client who has just returned to the unit from the PACU b. A client who has a closed head injury and increased intracranial pressure c. A client who has sickle-cell anemia and has completed an infusion of packed RBCs d. A client who reports acute chest pain 53. A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take? a. Tell the client to leave her purse in a drawer of the bedside table b. Offer to store the purse at the nurses’ station c. Offer to place the purse in the facility safe d. Place the purse in the clothing bag with the client’s other belongings 54. A case manager observes a family member of a client who has Alzheimer’s disease throwing books on the floor and sobbing while the client is having a diagnostic test. Which of the following actions should the case manager take first? a. Help the caregiver arrange for respite care b. Offer to have a brief talk with the caregiver c. Consult social services to explore counseling d. Refer the caregiver to a local support group 55. A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body? a. Green b. Yellow c. Black d. Red 56. A nurse is caring for a client who has early-stage Alzheimer’s disease. In which of thefollowing actions is the nurse acting as a client advocate? a. Performing an updated cognitive assessment on the client b. Requesting a referral for the client to attend reminiscent therapy sessions c. Providing assistance for the client when ambulating down the hall d. Reorienting the client several times throughout the day 57. A nurse is caring for a client who has a prescription for transcutaneous electrical nerve stimulation (TENS). Which of the following members of the interdisciplinary team should the nurse contact for assistance? a. Occupational therapist b. Respiratory therapist c. Pharmacist d. Physical therapist 58. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the following findings indicates the need for a referral to a wound care specialist? a. Minimal signs of induration at the wound edges b. Presence of granulated tissue over the wound c. Presence of slough in the wound bed d. Epithelialization noted in areas of tissue loss 59. A nurse is planning discharge for a client who has a new diagnosis of COPD and lives alone.Which of the following actions is the nurse’s priority? a. Suggest participating in a community support group b. Provide printed materials for new prescriptions c. Set up appointments for in-home physical therapy d. Request a referral for a home safety assessment 60. A charge nurse witnesses an assistive personnel (AP) giving an oral medication to a client who has dysphagia. Upon questioning, the AP states that a nurse poured the medication into a cup and asked the AP to give it to the client. Which of the following actions should the charge nurse take first? a. Reinforce facility policy regarding medication administration with the AP b. Discuss the situation with the nurse who poured the medication c. Complete the appropriate documentation of the incident d. Auscultate the client’s breath sounds 61. A nurse is observing assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Administers the solution at room temperature b. Positions the client on her left side with knees flexed c. Inserts the tubing 8 cm (3.1 in) into the rectum d. Points tubing in the direction of the umbilicus during insertion 62. A nurse is preparing to transfer a client to the radiology department using a wheelchair. Which of the following actions should the nurse take? a. Leave a transfer belt in place until the client returns from radiology b. Keep the footplates lowered throughout the transfer process c. Push the wheelchair into the elevator, large wheels last d. Test the locks on both wheels of the chair prior to transfer 63. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system? a. Introduce the new scheduling system by describing how it will save the institution money b. Offer to reassign staff who do not support the change to another unit c. Identify nurses who accept the change to help influence other staff nurses - check d. Provide a brief overview of the new scheduling system immediately before its implementation 64. A nurse is planning discharge for a client following a hip arthroplasty. The client tells the nurse that she lives alone. Which of the following actions should the nurse take first? a. Report the information to the provider b. Contact the case manager for a consultation c. Determine the specific needs of the client d. Document the client’s living situation in the medical record 65. A charge nurse is making assignments for a medical-surgical unit. Which of the followingclients is appropriate to assign to a licensed practical nurse? a. A client who has emphysema and has an oxygen saturation level of 92% b. A client who is scheduled to start oral nutrition 2 days after stroke c. A client who is scheduled to receive 2 units of RBCs following a hip replacement d. A client who has dehydration and is being admitted from the emergency department 66. 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. Place a faulty equipment tag on the pump b. Auscultate the client’s lungs c. Complete an incident report d. Notify the provider 67. A nurse is discussing advance directives with a client. Which of the following statements by the client indicates an understanding of advance directives? a. I know I have the right to determine if I remain on a breathing machine b. I know I’ll need a lawyer to change them later, so I want to get them right c. I trust my doctor, so I’m going to leave it to him to do what’s best for me d. By naming a health care proxy, I give up the right to make my own medical decisions 68. A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first? a. Two nurses had a heated disagreement about a scheduling issue b. No transport assistance is available to take a client to physical therapy c. Three staff members have called to say they will be absent d. A client is refusing care from assistive personnel of the opposite gender 69. A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out his IV catheter. Before using wrist restraints, which of the following actions must the nurse take first? a. Attempt less restrictive alternatives b. Explain the procedure to the client and his family c. Obtain a prescription for restraints from the provider d. Document the indications for using wrist restraints 70. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan? a. Return unused supplies from the bedside to the unit’s supply stock b. Wait to dispose of sharps containers until they are completely full c. Use clean gloves rather than sterile gloves for colostomy care d. Store opened bottles of normal saline in a refrigerator for up to 48 hr HESI Leadership 1. A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate to the nurse the need for referral to an occupational therapist? a. Facial drooping b. Receptive aphasia c. Unilateral neglect d. Memory loss 2. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Which of the following is an appropriate task for the AP? a. Show a new mother how to change the newborn’s diaper b. Inspect the skin of a newborn who is receiving phototherapy c. Obtain the weight of a newborn who is receiving formula d. Answer the parents’ questions about newborn circumcision 3. A charge nurse is planning the care of four newborns. An assistive personnel and licensed practical nurse are available for staffing. Which of the following tasks should the nurse assign to a licensed practical nurse? a. Conduct the newborn hearing screening b. Perform a New Ballard screening c. Administer a hepatitis B vaccine d. Obtain vital signs 4. A nurse is completing discharge teaching with a client who is being treated for tuberculosis (TB). Which of the following statements by the client indicates an understanding of the teaching? a. I need to have a TB skin test done once per year b. I need to take my prescribed medication for 3 months c. I should have a sputum culture done every 2 to 4 weeks d. I should wear a mask while around my family 5. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experience to safely care for his assigned clients. Which of the following actions should the nurse take? a. Accept the assignment with help from assistive personnel on the unit b. Document the concern in the nurse’s notes c. Notify the risk manager d. Request that the charge nurse modify the assignment 6. A nurse is conducting an in-service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy? a. Recommending a referral for a client who requires physical therapy b. Suggesting a client’s partner attend a support group for emotional support - check c. Completing an incident report following a medication error d. Evaluating a client’s home for safety hazards 7. A nurse is caring for a group of clients. Which of the following clients should the nurse plan to assess first? a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr b. A client who has diabetes mellitus and reports paresthesia in his fingers and toes c. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL d. A client who has a nasogastric tube and has crackles in the lungs 8. A staff development nurse is giving an in-service presentation about advocacy in nursing. Which of the following statements by a nurse indicates an understanding of the role of a client advocate? a. As a client advocate, I will suggest the best course of action for clients who are indecisive b. In the role of client advocate, I should take responsibility for coordinating each client’s care c. My role as a client advocate is to empower the clients to make informed health care decisions d. As a client advocate, I will adhere to the provider’s prescribed treatments 9. A charge nurse in the emergency department is supervising a nurse who is floating from the medical-surgical unit. Which of the following assignments is appropriate for the float nurse? a. Set up a trauma room for an incoming client who was in a motor-vehicle crash b. Perform a urinary catheterization for a client who has experienced a stroke - check c. Administer IV nitroglycerin to a client who is experiencing chest pain d. Complete a SAD PERSONS assessment scale for a client who has attempted suicide 10. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary? a. I will need assistance with bathing - check b. I am tired of having pain in my joints all the time c. I’m having difficulty climbing the stairs at my house d. I need some help planning my meals to maintain my weight 11. 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 turns her back to the sterile field b. The nurse puts on a face mask c. The nurse holds her hands above her waist d. The nurse applies goggles 12. A home health nurse finds piles of newspapers in the hallway of a client’s home. The nurse explains the need to discard the newspapers for safety reasons. The client agrees to move the newspapers into the living room. Which of the following conflict resolution strategies has the nurse used? a. Compromising b. Accommodating c. Collaborating d. Smoothing 13. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles? a. Nonmaleficence b. Veracity c. Autonomy d. Utility 14. 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 facility ethics committee reaches a consensus on the case b. Whether the client understands the risk of refusing the procedure c. Whether the client’s refusal is based on religious belief d. Whether the partner is the client’s durable power of attorney for health care 15. 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 refusesto 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. Assess the client for urinary retention c. Obtain a provider’s prescription for a blood alcohol level d. Document the client’s refusal in the chart 16. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used for a client who has C. dif. Which of the following solutions should the nurse recommend to clean the equipment? a. Chlorine bleach b. Isopropyl alcohol c. Triclosan d. Chlorhexidine 17. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the following clients should the nurse assess first? a. A client who reports a headache with sensitivity to light b. A client who reports feeling lightheaded when he stands up from a lying position c. A client who reports indigestion and pain in her jaw d. A client who reports an urge to void but has not urinated during the prior shift 18. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage bone cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care? a. Does the AP have time to change the client’s central IV-line dressing after turning her? b. Is the client’s family present so the AP can show them how to turn the client? c. Has the AP checked the client’s pain level prior to turning her? d. Has data been collected about specific client needs related to turning? 19. A nurse is preparing a client for an elective mastectomy. The client is wearing a plain gold wedding band. Which of the following is an appropriate procedure for taking care of this client’s ring? a. Place the client’s ring in the facility safe b. Tape the ring securely to the client’s finger c. Place the ring in the bag with the client’s clothing d. Agree to keep the ring for the client until after surgery 20. A nurse is planning care for a client who has Addison’s disease. Which of the following tasksshould the nurse plan to delegate to assistive personnel? a. Explain to the client about a 24-hr urine specimen collection b. Remind the client to change positions slowly c. Decide how often to measure vital signs d. Determine the client’s muscle strength prior to ambulation 21. A nurse is preparing a client for a cardiac catheterization. Just before the procedure, the client asks the nurse about the risks of the procedure. Which of the following actions should the nurse take? a. Check to see if the medical record indicates the provider explained the procedure to the client b. Explain the risks of the procedure to the client c. Notify the provider about the client’s concerns d. Convey the client’s request to the nurse who witnessed the consent 22. MISSING 23. A nurse is providing information to a client about advance directives. The nurse should explain that advance directives include which of the following? a. Information regarding organ donation b. A form with directions for contacting next of kin c. Instructions regarding treatments the client desires or does not desire d. Information regarding the disposition of the client’s body upon death 24. A nurse is prioritizing postpartum care for four clients. Which of the following actions should the nurse take first? a. Instruct a client who has an episiotomy about a sitz bath b. Check uterine tone for a client who received methylergonovine c. Assist a client who requests help breastfeeding her 4-hr-old newborn d. Administer Rh immune globulin to a client who is Rh-negative and 6 hr postpartum 25. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN? a. Admitting a new client who has chronic back pain to the unit b. Ambulating a client who is scheduled for discharge later in the day c. Administering morphine IV bolus to a client who is 4 hr postoperative d. Reinforcing teaching with a client who is learning to self-administer insulin 26. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? a. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot b. A client who has MRSA and has an axillary temperature of 38 C (101 F) c. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void 27. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which ofthe following statements by a staff nurse indicates understanding? a. HIPAA allows clients to request a review of their own medical records b. HIPAA prohibits the uploading of photographs of client’s providers to social medical sites c. HIPAA allows facility-specific coding of client health care information to ensure privacy d. Clients who participate in research studies forfeit their HIPAA right to privacy 28. An infection control nurse is planning an education program for a group of newly licensed nurses. Which of the following infections should the nurse include when discussing illnesses requiring droplet precautions? a. Rotavirus b. Varicella c. Mumps d. Rubeola 29. A nurse in the emergency department is caring for a 16-year-old client who reports abdominal pain and is accompanied by an adult neighbor. The provider diagnoses a ruptured appendix and states that the client requires an emergency appendectomy. Which of the following actions should the nurse take? a. Obtain consent from the hospital administrator b. Witness the client signing the consent form c. Attempt to notify the client’s guardian to obtain consent d. Ask the adult neighbor to sign the consent form 30. 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. Complete an incident report b. Notify the provider c. Place a faulty equipment tag on the pump d. Auscultate the client’s lungs 31. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I will remove a client’s restraints every 4 hours b. A provider can write a prescription for restraints as needed c. I need to tie the restraint to the part of the bed frame that moves d. I should tie the restraints using a square knot 32. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take? a. Report the staff nurse to the facility ethics committee b. Counsel the staff nurse about substance use c. Collect data about the staff nurse to support further action - check d. Assign clients who are not prescribed narcotics to the staff nurse 33. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse? a. Administer a nasogastric tube feeding b. Pick up the meal trays after lunch c. Determine adequacy of ventilator settings d. Plan break times for assistive personnel 34. A nurse is observing an assistive personnel (AP) administer a 0.9% sodium chloride enema to an adult client. For which of the following actions by the AP should the nurse intervene? a. Inserts the tubing 8 cm (3.1 in) into the rectum b. Positions the client on her left side with knees flexed c. Administers the solution at room temperature d. Points tubing in the direction of the umbilicus during insertion 35. A nurse is planning to discharge a client who has terminal cancer and suggests that the family might benefit from respite services. When the client’s partner asks how this service can help, which of the following responses by the nurse is appropriate? a. This service delivers meals and supplies to reduce your errands away from home b. The clinicians help reduces the severity of your wife’s physical problems c. It makes it possible for you to have some time away from caring for your wife d. This service offers psychological interventions during and after your wife’s illness 36. A nurse is planning to delegate client care assignments. Which of the following tasks should the nurse plan to delegate to assistive personnel? a. Teaching a client to perform a finger-stick for testing blood glucose levels b. Performing postmortem care prior to transferring the client to the morgue c. Informing a family of a client’s progress in physical therapy d. Advising a client on self-administration of acetaminophen 37. A nurse is caring for four clients. Which of the following tasks can be delegated to assistive personnel? a. Reviewing dietary instructions for a client who has kidney stones b. Monitoring a client who has a fluid restriction c. Assessing a client who just returned from hemodialysis d. Obtaining a stool sample from a client who has renal failure 38. 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 c. Recommend the client reuse the testing lancets d. Ask the provider about the possibility of less frequent monitoring 39. A case manager is reviewing documentation on several clients and notes a progress report that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse manager should identify that which of the following torts has occurred? a. Slander b. Negligence c. Libel d. Battery 40. During a staff meeting, a unit manager reviews the results for documenting client education and finds that they are below the benchmark. Which of the following strategies should the nurse manager implement first? a. Include documentation of client education as part of unit nurses’ annual performance evaluation b. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark c. Determine factors that interfere with the documentation of client education d. Train LPNs to reinforce teaching with clients using a standardized teaching plan 41. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to assistive personnel? a. Checking the pulses of the client’s right foot b. Determining the client’s pain level c. Recording the client’s vital signs d. Turning the client 42. A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first? a. The emergency department nurse is waiting to give report on a new admission b. Transport assistance is unavailable to take a client to occupational therapy c. Two staff members have called to say they will be absent d. A nurse on the previous shift wrote an incident report about a medication error 43. A home health nurse is assessing the home environment during an initial visit to a client who has a history of falls. Which of the following findings should the nurse identify as increasingthe client’s risk for falls? (Select all that apply.) a. A raised vinyl seat on the toilet in the bathroom b. A folding chair without arm rests c. A two-wheeled walker used to assist the client with ambulation d. A wheeled office chair at the client’s computer desk e. A throw rug covering some cracked vinyl flooring in the kitchen 44. A nurse is providing discharge teaching to a client following a total knee arthroplasty. Which of the following information should the nurse include? (Select all that apply.) a. Advance directives information b. Medication guideline information c. Insurance information d. Contact information for the physical therapist e. Information about follow-up care 45. A nurse at the local health department is caring for four clients who have communicable diseases. Which of the following infections should the nurse report to the state health department? a. Pediculosis capitis b. Candida albicans c. Impetigo contagiosa d. Chlamydia trachomatis 46. A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take? a. Proceed with treatment without obtaining written consent b. Notify risk management before initiating treatment c. Have the client sign a consent for treatment d. Contact the client’s next of kin to obtain consent for treatment 47. 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. Guardian consent is required for an emancipated minor b. Consent can be given by a durable power of attorney c. A family member can interpret to obtain informed consent from a client who is deaf d. The nurse can answer any questions the client has about the procedure 48. A nurse is caring for a client who has cancer. The client and her partner are asking the nurse about hospice care. Which of the following statements by the nurse is appropriate? a. Hospice care is a multidisciplinary program for clients who are terminally ill b. Hospice care will prolong the life expectancy of clients who are terminally ill c. Hospital access is no longer available for clients who are in hospice care d. Hospice care is helpful for clients at various stages of chronic illness 49. A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take? a. Administer the benzodiazepine but withhold the opioid b. Contact the provider about replacing the opioid with an NSAID c. Continue the medication dosages that relieve the client’s pain d. Withhold the benzodiazepine but continue the opioid 50. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first? a. Review facility policies for taking scheduled breaks b. Discuss time management strategies with the nurses c. Determine the reasons the nurses are not taking scheduled breaks d. Provide coverage for the nurses’ breaks 51. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings isthe highest priority? a. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids b. A client who has COPD and has an oxygen saturation of 90% c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication d. A client who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds 52. A nurse who is caring for a group of clients delegates collection of vital signs to assistive personnel (AP). Which of the following actions should the nurse take to evaluate the delegated task? a. Recheck vital signs that are outside the expected reference range b. Ask the AP to write a summary of the delegated tasks during the shift c. Review vital sign trends at the end of the shift d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift 53. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the following diseases should the nurse report to the state health department? a. Rotavirus b. Group B streptococcal disease c. Pertussis d. Respiratory syncytial virus 54. A nurse in a long-term care facility should identify that which of the following will providesecurity for clients who have dementia? a. Setting alarms on exits b. Turning off room lights at night c. Restricting space to reduce pacing d. Using a facility-wide paging system 55. A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first? a. Report the possible violation of client confidentiality to the nurse manager b. Complete an incident report regarding the breach of the client’s confidentiality c. Recommend the son meet the provider to get information about his mother’s condition d. Log out the computer so that the client’s son is unable to view his mother’s information 56. A nurse is preparing to transfer a client from the emergency department to a medical- surgical unit using the SBAR communication tool. Which of the following information should thenurse include in the background portion of the report? a. A prescribed consultation b. The client’s vital signs c. The client’s name d. The client’s code status 57. 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. Determine client care goals b. Complete required tasks c. Document assessment data d. Review the client’s new laboratory values 58. A nurse is participating in the development of a disaster management plan for a hospital. The nurse should recognize that which of the following resources is the highest priority to have available in response to a bioterrorism event? a. A sufficient supply of personal protective equipment b. A network for communication between staff members and families c. A system for tracking client information d. A mental health specialist on the response team 59. 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 techniques? (Select all that apply.) a. Holds the sterile solution bottle with the label facing up b. Prepares a container of sterile solution on the field after putting on sterile gloves c. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field d. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field e. Opens the sterile pack by first unfolding the top flap away from her body 60. A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take? a. Ask the client about his injuries with the son present b. Ask the client’s son to go to the waiting area c. File an incident report d. Treat and discharge the client 61. A nurse is reviewing the medication administration record of a client and notices that an additional dose of medication has been administered. Which of the following actions should the nurse take first? a. Notify the provider b. Inform the nursing supervisor c. Observe the client’s condition d. Complete an incident report 62. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors. Which of the following actions should the charge nurse take first? a. Identify education opportunities for the nurse regarding safe medication administration b. Review with the nurse the principles of medication administration c. Notify the risk management department of the situation d. Ask the nurse to describe her medication administration procedure 63. 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. A young adult client who is participating in a medical research study c. An adolescent client whose parents refuse a blood transfusion for religious reasons d. An older adult client who has advance directives on file 64. A nurse in an ambulatory care setting is orienting 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. Developing client treatment protocols b. Establishing communication between providers c. Assessing client needs d. Providing medication reconciliation 65. A nurse is triaging a group of clients following a disaster. Which of the following clientsshould the nurse recommend for treatments first? a. A client who has a neck injury and is unable to breathe spontaneously b. A client who has major burns over 75% of her body surface area c. A client who has bipolar disorder and is exhibiting signs of hallucination d. A client who has two open chest wounds with a left tracheal deviation 66. A charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first? a. A client who is in Buck’s traction for a left hip fracture b. A client who is confused and restrained for safety c. A client who is receiving IV chemotherapy and is ambulatory d. A client who is 1-day postoperative following thoracic surgery and has a chest tube 67. A nurse is assessing a client’s comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure? a. I will be given contrast dye during this test b. I will run on a treadmill during this test c. I might have to wear a nose clip during this test d. I might have a tube inserted into my airway during this test 68. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take? a. Recommend that both nurses be terminated b. Contact the house supervisor to mediate the conflict - check c. Make arrangements to take over the client’s care d. Escort the nurses to the nurses’ lounge to continue the discussion 69. A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first? a. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 b. An adult client who has large ecchymosis on both legs c. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood d. An older adult client who has dyspnea and a respiratory rate of 26/min 70. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include? a. Warm the hands prior to piercing the skin b. Obtain the blood sample from the finger pads c. Cap the lancet prior to putting it in the trash d. Elevate the arm for 1 min before taking the blood sample HESI Leadership 1. A nurse is caring for several clients. Which of the following actions should the nurse take to maintain client confidentiality? A. Tell a client’s partner that the results of his wife’s lab tests cannot be disclosed without her permission B. Ask the assistive personnel to refer to clients by room number in public areas C. Explain to a student nurse that verbal permission must be obtained before using a client’s name in school assignments D. Share info about a client with immediate family members after personal ID has been provided 2. A nurse is caring for a client who asks for info about advance directives. Which of the following is an appropriate response by the nurse? *** A. Your advance directives will take effect when you are unable to make health care decisions B. You will not be able to make changes to the advance directives once you sign it C. Your advance directives can specify which medical care you do not want but cannot specify which medical treatments you can have D. You must have advance directives on record within 24hr of a hospital admission 3. A nurse assumes care of a client following morning report and notes that the client’s morning lab results have not been received. Which of the following actions should the nurse take? A. Administer the client’s insulin as prescribed B. Give the NPH and hold the regular insulin until the lab results are back C. Obtain a capillary blood glucose reading D. Hold the client’s breakfast until the lab results are back 4. A nurse on a med-surg unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority? A. A client scheduled for a tubal ligation in 2hr who is crying B. A client who has peripheral vascular disease and has an absent pulse in the right foot C. A client who has type 1 DM and needs the first dressing change for a stage II decubitus ulcer D. A client who has MRSA and has an axillary temp of 38C (100.4F) 5. A nurse has four client assignments on a maternal newborn unit. Which of the following tasks can be delegated to an AP? A. Verifying the mother’s fundal height B. Assisting the mother with cord care C. Showing the mother how to position the newborn for sleep D. Measuring output of the mother’s first voiding 6. An AP tells the charge nurse that it is unfair that she has to take care of all the clients who are incontinent. Which of the following responses by the charge nurse is appropriate? A. I delegate tasks to personnel based on their job descriptions B. Everyone working here has to care for clients who are incontinent C. Let’s talk about organizing the workflow so you care for fewer of these clients D. Why do you not want to care for clients who are incontinent? 7. A client is considering having a tubal ligation, and she tells the nurse that she is uncertain if it is the right thing to do. Which of the following is an appropriate response by the nurse? A. Provide information on alternate birth control methods B. Ask the client if she has her partner’s approval C. Emphasize the benefits of having the procedure D. Discuss with the client her feelings about the procedure 8. A nurse manager is reviewing the stages of conflict resolution with the nursing staff. The nurse manager should instruct the staff to expect the stages of the conflict to occur in what order? A. Conflict aftermath 5 B. Felt conflict 3 C. Manifest conflict 4 D. Latent conflict 1 E. Perceived conflict 2 9. A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? Select all that apply A. The right to be treated with respect and dignity B. The right to full access of the facility C. The right to refuse their medications D. The right to leave regardless of provider recommendations E. The right to be fully informed of their health conditions 10. A nurse is witnessing a client sign the consent form for a surgical procedure. The client has a question regarding alternative treatments. Which of the following actions should the nurse take? A. Review the surgical procedure described on the consent form with the client B. Provide the client with education materials about the procedure C. Answer the client’s question and have the client sign the consent form D. Call the surgeon to discuss alternative treatments with the client 11. A nurse is planning discharge care for an older adult client who has RA. The nurse notes that the client is having difficulty buttoning her clothing. Which of the following is an appropriate referral for the client? A. Pain management clinic B. Physical therapy C. Adult day care D. Occupational therapy 12. A nurse from a medical unit is asked to work on an orthopedic unit. The medical nurse has no ortho experience. Which of the following clients should be assigned to the medical nurse? *** A. A client in balance skeletal traction B. A client who had a total hip arthroplasty 3 days ago C. A client who has a fractured femur with a new cast D. A client who had a right above-the-knee amputation 24hrs ago 13. A client who is being D/C today asks the nurse for supplies for his wound dressing. Which of the following actions should the nurse take to ensure quality, cost-effective car? A. Ask the client how many supplies he wants B. Provide enough supplies for 1-2 days C. Check the client’s insurance before acting D. Explain that no supplies are given for home use 14. An older adult-client is being D/C with a postop infection, requiring daily home IV antibiotics through a PICC line. Which of the following actions should the case manager perform prior to discharge? A. Assess the client’s home environment for possible reservoirs of infection B. Verify the patency of the PICC line C. Provide dressing change and wound assessment teaching D. Ensure that home infusion therapy has been arranged 15. A home health nurse is performing a home safety assessment for a family who has toddler. Which of the following findings is a potential environmental hazard the nurse should discuss with the parents? A. The crib mattress is positioned at the lowest level B. The toy box does not have a hinged lid C. The toilet seat lid is in the raised position D. There is a throw rug under the toddler’s crib 16. A nurse manager is presenting an in-service about preventing readmission of clients due to complications after joint replacement surgery. Which of the following leadership tasks is the nurse performing? A. Collaboration B. Mediation C. Negotiation D. Advocacy 17. A nurse is reviewing a safe use of a wheelchair with a group of AP. Which of the following should the nurse include? A. Raise the footplates of the wheelchair before transferring the client B. Lock the brake on one wheel of the chair when transferring the client C. Push the wheelchair into the elevator with the front wheels first D. Stand behind the wheelchair when moving a client down a ramp 18. A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following should the charge nursedo? Select all that apply A. Role model a positive approach to the changes B. Redirect the conversation when negative comments about the changes are made C. Encourage staff members who support the changes to discuss the issue with resistant staff D. Suggest that resistant staff members transfer to a different unit E. Reprimand staff members who are resistant to the changes 19. A charge nurse is planning client care assignments for the unit. Which of the following clients should the nurse assign to an LPN? A. A client who has anemia and is scheduled for a blood transfusion B. A client who has Crohn’s disease and requires an enteral feeding C. A client who has a new diagnosis of diabetes and requires teaching for self-administration of insulin D. A client who has a pulmonary embolism and is receiving an IV infusion of heparin 20. A nurse is caring for a client who has acute diverticulitis and is scheduled for surgery within the next 2 hr. The client tells the nurse that she has called a taxicab and is leaving the hospital. After notifying the surgeon, which of the following actions should the nurse take next? A. Have the client sign the “Against Medical Advice” form B. Inform the client about the risks she may encounter by leaving the facility C. Document the client’s statements in the medical record D. Notify the risk manager 21. A nurse is observing a newly licensed nurse who is performing a sterile dressing change on a client who has a central venous catheter. Which of the following is an appropriate action by the newly licensed nurse? A. Opens the top flap of the sterile package toward herself B. Maintain a 1.25cm (1/2 inc) border around the edges of the sterile field C. Picks up first sterile glove by grasping the folded cuff edge D. Places the transparent dressing using clean gloves 22. A client presents to the ED with weakness, vomiting, and diarrhea for the past 3 days. Which of the following is the highest priority assessment for this client? A. Bowel sounds B. The client’s temperature C. Urine specific gravity D. Serum potassium level 23. A nurse is caring for a client who is refusing a blood transfusion due to religious beliefs. The provider discusses this treatment and likely outcomes with the client, who remains opposed to the transfusion. Which of the following is the appropriate intervention for the nurse? A. Have the provider reinforce the necessity of the transfusion B. Encourage the family to persuade the client to reconsider the transfusion C. Ask the chaplain to convince the client that the transfusion is acceptable D. Support the client’s decision to forego the transfusion 24. A client seen in the ED for back pain is provided a prescription for oxycodone. A staff nurse tells the charge nurse that she thinks the client is seeking drugs and is not actually in distress. Which of the following responses by the charge nurse is appropriate? A. Clients are the experts on their own pain B. Let’s withhold the oxycodone until we can consult with the provider C. Contact mental health services to arrange for a consultation D. It sounds like non-pharmacological interventions would be best for this client 25. A charge nurse is discussing issue with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects and intrapersonal conflict? A. I’m not sure whether I want to apply for the unit manager’s position or start a family this year B. I feel frustrated because I just readmitted a client who refuses to take his insulin C. The unit manager is more concerned with saving money than with clients getting quality care D. Every time I request an extra day off I’m denied, but other nurses’ requests are approved 26. An older adult client is brought to ED by family members. The client has stage IV pressure ulcers, and a close inspection of the wounds reveals the presence of maggots. Which of the following is the nurse’s legal responsibility regarding this situation? A. Confront the family members B. Call the local police department C. Notify Adult Protective Services D. Report the situation to facility administrators 27. A nurse working in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease? A. Respiratory syncytial virus (RSV) B. MRSA C. C-diff D. Chlamydia trachomatis 28. A charge nurse is talking with a staff nurse following a workshop on advance directives. Which of the following statements by the staff nurse demonstrates understanding of advance directives? *** A. A client’s advance directives are not valid until the provider writes a prescription B. A health care proxy should make decisions for a client who has a terminal illness C. A family member of a client can have the living will overturned in some cases D. A client who has an acute illness may not have a DNR prescription 29. A nurse working in a long-term care facility is making a room assignment for a client who has dementia and is easily agitated. Which of the following rooms should the nurse select for the client? A. A semiprivate room near the unit’s activity room B. A newly renovated room near the entrance of the unit C. A corner room between the conference room and elevator D. A private room near the nurse’s station 30. A charge nurse is planning care for a group of clients. Which of the following tasks should be delegated to an AP? Select all that apply A. Flushing a client’s saline lock B. Ambulating a client who uses a walker C. Adding thickener to thin liquids on a client’s food tray D. Showing a client how to use an incentive spirometer E. Evaluating a client’s gag reflex before mealtime 31. A charge nurse is assigning tasks to an RN, an LPN, and an AP. Which of the following tasks should the charge nurse delegate to the RN? A. Completing an admission assessment for a client who has just transferred from the ED B. Inserting an indwelling urinary cath for a client who has not voided for 6 hr C. Assisting a client who is 12hr post op from eye surgery to ambulate D. Obtaining a sterile specimen from a client’s infected surgical wound 32. A staff nurse detects alcohol on the breath of another nurse working on the unit. He observes that her gait seems unsteady, and she occasionally slurs her speech. Which of the following actions should the nurse take if he suspects that his colleague is under the influence of alcohol? A. Notify the charge nurse of his assessment B. Confront the impaired nurse regarding his suspicions C. Wait to see if the behavior occurs again before taking action D. Suggest to the nurse that she request sick leave for the rest of the shift 33. A nurse is receiving change-of-shift report at the start of the shift. Which of the following clients should the nurse assess first? A. A client who has a WBC count of 15,000/mm3 and is receiving antibiotics B. A client who had abdominal surgery 6hr ago and has a HR of 120 for the last 2 hr C. A client who is requesting pain meds 24hr after an ORIF of the left ankle D. A client who has pneumonia and is refusing prescribed medication 34. A nurse finds that a new IV pump has infused 400mL of solution over 2hr when the rate was set at 100mL/hr. After notifying the provider and verifying that the pump was properly programmed, which of the following is thenurse’s highest priority? A. Fill out an incident report and submit it to the nurse manager B. Consult with the other nurses who have experience with this type of pump C. Tag the pump for maintenance and acquire a new pump for the client D. Call the biomedical engineering dept and report the problem 35. A nurse case manager is developing a critical pathway for clients who have pneumonia. Which of the following data should the nurse include? A. Type of insurance B. Home medication C. Significant others D. Treatment milestones 36. A nurse receives report on 4 clients. Which of the following clients should the nurse assess first? A. A client admitted with COPD who has a pulse ox reading of 90% on 2L/min of oxygen B. A client admitted with acute pancreatitis whose PCA cassette is nearly empty C. A client admitted for a fractured hip who has developed slurred speech D. A client admitted with bronchitis who is reporting pain on inspiration 37. A nurse manager finds that there has been an increase in UTIs on the unit. To address this problem, the first action the nurse manager should take is to A. Conduct an in-service that reviews proper catheter insertion and maintenance B. Perform a chart review to gather data about the clients who developed infections C. Observe each staff nurse perform a urinary catheter insertion D. Require completion of a self-paced instruction program 38. A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A. A student nurse is photocopying his assigned client’s diagnostic test results B. An AP documents a client’s vital signs on the client’s paper-based graphic record C. The unit secretary faxes a client’s lab results to the provider D. An RN stays with a client who is reading the medical records that he requested 39. A nurse is caring for a group of clients on a unit. Which of the following assessment findings should the nurse recognize as the priority to report to the charge nurse? A. A client who has heart failure and has 2+ edema of her lower extremities B. A client who is 2 days postop and has a urine output of 20mL/hr C. A client who started taking atenolol and reports feeling lethargic D. A client receiving morphine and reports nausea 40. A nurse in the ED is performing triage for a group of clients following a MVC. Which of the following clients should the nurse request the provider assess first? A. A client who has a closed leg fracture and reports peripheral paresthesia B. A client who reports a sprained ankle and has a laceration over the medial ankle C. A client who has arm contusions and manifests asymmetrical thoracic movement D. A client who has abrasions to the face and is requesting medication for severe pain 41. A facility has identified an increase in health care-associated UTIs on the med-surg unit. A nurse is participating in a quality improvement process to address this problem. Which of the following should be the first step in the process? A. Determine the effectiveness of planned interventions B. Implement strategies to decrease the incidence of UTIs C. Develop a plan that outlines the process for data collection D. Establish best practice guidelines for reducing the incidence of UTIs 42. A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice a day. Which of the following is an appropriate action for the charge nurse to take? *** A. Perform the dressing change himself on rounds B. Delegate the procedure to an AP C. Assign the procedure to an LPN D. Reschedule the procedure to be performed once per day 43. A charge nurse is evaluating a newly licensed nurse at the end of orientation. Which of the following behaviors indicates the nurse is using effective time management skills? A. Performs total care for her assigned clients B. Waits to complete charting until the end of the shift C. Uses a set list of priorities throughout the shift D. Makes a list of non-essential tasks to perform later 44. A hospital has been notified of a train derailment resulting in multiple clients experiencing life-threatening injuries. The external disaster plan has been activated. Which of the following is an appropriate action of the charge nurse on the PACU? *** A. Take extra wheelchairs to the ED B. Send PACU AP to assist with triage C. Identify stable clients for transfer to a surgical unit D. Report to the command center for further instructions 45. A nurse is caring for a client who is 3 days postop following open heart surgery and is to transfer to the medical- surgical unit. Which of the following should the nurse plan to include in the verbal report? A. The client’s dressing change schedule B. The client’s LOC C. The client’s vital signs from the previous shift D. The client’s occupation 46. A case manager is initiating the plan of care for a client receiving warfarin who had a stroke. Which of the following is most important for the case manager to include in the client’s plan of care? A. Scheduling follow-up tests for prothrombin time and INR B. Making a referral to speech therapy C. Arranging physical therapy home visits D. Providing client education related to dietary restrictions 47. A nurse manager needs to address an increased rate of client med errors. Which of the following strategies represents an authoritarian approach to managing this issue? A. Inform the staff of the penalties that can result from med errors B. Encourage the staff to have 2 nurses verify medication orders to prevent errors C. Provide a suggestion box for the staff to submit ideas for error prevention D. Ask 3 experienced nurses to help investigate common causes of the errors 48. A charge nurse is responsible for a caseload of clients on a surgical unit. Which of the following occurrences during the shift requires the completion of an incident report? A. A client’s advance directives are not in the med record B. A nurse administers a routine medication 30 min after the scheduled time when the client returns from physical therapy C. A client’s IV solution infused over 6 hr instead of the prescribed 8 hr D. A nurse documents a client’s vital signs on the graphic record at the end of the shift 49. A nurse manager is coordinating staff assignments for RNs and LPNs following a local disaster. Which of the following is an appropriate assignment by the nurse manager to provide safe and effective client care? *** A. RNs transport class IV (black tag) clients B. LPNs provide care to class III (green tag) clients C. LPNs initiate care to class I (red tag) clients D. LPNs facilitate care to class II (yellow tag) clients 50. An RN delegates the task of obtaining the BP of a client who is 2hr postop following a cholecystectomy to an LPN. The LPN reports a BP that is significantly higher than the client’s previous reading. Which of the following actions should the RN take first? A. Recheck the client’s BP B. Treat the client’s BP with a prescribed antihypertensive C. Ask the LPN to review the technique for obtaining BP D. Review the client’s medical record for other episodes of elevated BP 51. A charge nurse is performing chart reviews on infection control precautions implemented by nursing personnel during the admission of clients to the unit. Which of the following is an appropriate infection control precaution? A. Droplet precautions for a client who has meningococcal pneumonia B. Airborne precautions for a client who has shigella C. Droplet precautions for a client who has MRSA D. Airborne precautions for a client who has RSV 52. A staff nurse at a long-term care facility is evaluating an AP caring for a group of clients who require restraints. Which of the following is an appropriate action by the AP? A. Securing mitten restraints around the forearm B. Using a square knot when securing the restraint strap C. Applying the belt restraint beneath the client’s clothing D. Placing the restraint tie on a moveable part of the bed frame 53. A nurse case manager is planning a teaching session on use of critical pathways with a group of newly licensed nurses. The nurse should include which of the following in the teaching about critical pathways? A. Critical pathways promote individualized care B. Critical pathways decrease administrative work time C. Critical pathways prevent unnecessary expense D. Critical pathways incorporate provider preferences 54. A nurse is reviewing facility data on hand hygiene adherence and finds that nurses are not performing hand hygiene after client contact 28% of the time. Which of the following is the first action the nurse should take when developing a plan to increase employee hand hygiene adherence? A. Schedule training sessions to teach proper technique B. Provide alcohol-based hand wash outside of each client’s room C. Identify a way to measure hand hygiene adherence D. Set a goal for improvement in adherence 55. A nurse manager is developing a class for newly licensed nurses on strategies to promote client rights. Which of the following should the nurse manager include in the teaching? A. Spend equal amounts of time providing care for each client B. Verify that a provider prescription is in the medical record for clients who have restraints C. Ensure that competent clients do not leave the hospital without medical discharge D. Present the purpose, risks, and benefits of a surgery when the provider is unavailable 56. A charge nurse on a medical unit hears the fire alarm and announcement that a fire is occurring on the unit. Which of the following is the priority action by the charge nurse? A. Turn off the oxygen supply valve to the unit B. Instruct ambulatory clients to go to a safe area C. Verify that unit fire doors are closed D. Direct personnel to use fire extinguishers 57. A nurse is caring for a school-age client who is seeking treatment for a laceration to the right forearm that occurred during soccer practice. The client was transported to the ED by a friend’s parent and the soccer coach. The nurse should ensure that informed consent is given by A. The client B. The friend’s parent C. The client’s guardian D. The soccer coach 58. A charge nurse is reviewing the plan care for a client who has active herpes simplex lesions. Which of the following interventions is appropriate for the plan of care? A. Admit the client to a private room with negative-pressure airflow B. Wear a gown and gloves when caring for the client C. Have the client wear a mask during transport D. Wear a face mask and eye protection when caring for a client 59. A nurse is caring for a client who has metastatic cancer and decides not to continue treatment. Which of thefollowing is an appropriate response by the nurse? A. Tell me what this is like for you B. Have you discussed your concerns with your doctor C. Is your family supportive of your decision to D/C treatment D. Have you considered trying alternative therapy for your cancer 60. A nurse has a friend who is a client on another unit. The nurse is concerned about the friend’s prognosis. Whichof the following is an appropriate action by the nurse? A. Review the friend’s medical records B. Page the primary care provider for information C. Ask the assigned nurse about the friend’s prognosis D. Ask the friend what the provider has told her HESI LEADERSHIP 1. A nurse is working on a quality improvement team that is assessing an increase in clients falls at the facility after problem identification which of the following actions should the nurse plan to take first as part of a quality improvement process a. Notify staff of increase fall rate b. review current literature regarding clients fall c. identify clients who are at risk for falls d. implemented A fall prevention plan 2. A client who is febrile is admitted to the hospital for the treatment of pneumonia. In accordance with the care pathway antibiotic therapy is prescribed which of the following situations require the nurse to complete a variance report with regards to the care pathway? a. The route of antibiotic therapy on the care pathway was from IV to PO b. A blood culture was obtained after antibiotic therapy had been initiated c. An allergy to penicillin requires an alternative antibiotic to be prescribed d. antibiotic therapy was initiated 2 hours after implementation of the care pathway 3. A nurse is caring for a client who has cancer the client and her partner are asking the nurse about Hospice care which of the following statements by the nurse is appropriate a. Hospital is no longer available for clients who are in Hospice care b. Hospice care will prolong the life expectancy of the client who are terminally ill c. Hospice care is a multi-disciplinary program for clients who are terminally ill d. hospice care is helpful for clients are very stages of chronic 4. A nurse manager discovers there is conflict between nurses working the day shift and the nurses working night shift. Which of the following actions should the nurse managertake first? a. Meet with a committee of nurses from each shift to discuss issues related to the conflict b. Gathering information regarding the situation c. Acknowledge the conflict and encourage the nurses to focus on working as a team d. Encourage the nurses to resolve the conflict autonomously 5. A nurse working in the emergency Department is assessing several clients which of the following clients is the highest priority a. A client who reports right sided flank pain and diaphoretic b. A client who has active bleeding from a puncture wound of the left groin area c. A client who has raised skin rash on his arm neck and face d. a client who reports shortness of breath and left neck and shoulder pain 6. A nurse is providing change your shift report to an oncoming nurse which of the following information should the nurse include in the report? a. The client is in the radiology department for a chest X Ray b. The client is the president of the local bank c. The client's partner came to visit him two hours ago d. the client has routine vital signs prescribed 7. A nurse is planning discharge for a client who had a lung reception. The nurse initiates a referral to a social worker which of the following assessment data supports his referral? a. client is to have a range of motion exercises Ambulation (OT) b. client is to have someone bring oxygen tanks and equipment to her home (CM) c. client needs to have someone come in to Help her bathe at home (CM) d. client needs to arrange financial resources to purchase equipment (CS) 8. A nurse is caring for client who request information about the prevalence of Tay-Sachs disease, which of the following resources should the nurse use to obtain this information a. The client’s health care provider b. an evidence-based nursing Journal special one c. A collaborate user- edited website d. The facility's case manager 9. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I can use another nurse’s password as long as I log off after using the computer b. I should encrypt personal health information when sending emails c. I should discard personal health information documents in the trash before leaving the unit d. I can post the clients vitals in the client's room 10. A nurse is providing instructions about chemotherapy for a client who has a new diagnosis of breast cancer. The client has decided to try an alternative treatment rather than starting chemotherapy which of the following actions should the nurse take a. Tell client they cannot change their mind once consent is given b. Inform the client about the risks of not starting chemotherapy immediately c. notify its spiritual services to speak with the client about their decision d. respect the client decision about not receiving chemotherapy 11. A charge nurse notices that two staff nurses are not taking meal breaks during their shift which of the following actions should the nurse take first? a. Discuss time management strategies with the nurses b. provide coverage for the nurse’s breaks c. review facility policies for taking schedule breaks d. determine the reasons the nurses are not taking a scheduled break 12. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube, the nurse should access the clients need for which of the following supplies to manage the tracheostomy at home (select all that apply) a. Obturator b. Cotton balls c. oxygen tank d. petroleum Jelly e. pipe cleaners 13. A nurse in the emergency Department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmias. Which of the following actions should the nurse take? a. Have the client sign a consent for treatment b. notify risk management before initiating treatment c. contact the clients next of kin to obtain consent for treatment d. proceed with treatment without obtaining written consent 14. A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following column reception. Which of the following resources should the nurse use? a. Provide prescription b. Maslow hierarchy of needs c. Surgical record d. critical pathway 15. A nurse who is precepting a newly licensed nurse is discussing the client assignments for the shift. Which of the following action should the nurse preceptor take first to demonstrate appropriate time management? a. Document assignment data b. determine clients care goals c. review the client new laboratory values d. complete required tasks 16. A nurse is planning preoperative teaching for a client who is scheduled for a cholecystectomy the client does not speak the same language as the nurse, she is accompanied by her adolescent daughter which of the following action should the nurse take? a. Use it bilingual dictionary to translate b. access the language line to interpret what is being said c. ask the client's daughter to interpret the conversation d. talk loudly while facing the client 17. A charge nurse is making room for new admissions following a community disaster which of the following clients should the nurse recommend for discharge? a. A client who has an angina and a troponin level of 3ng/ml b. a client who has a deep vein thrombosis an in INR of 2.0 c. a client who is receiving chemotherapy and has a tumor lysis syndrome d. a client who has a new onset of left sided weakness 18. A nurse is planning to discharge a client who has a terminal cancer and suggest that the family might benefit from respite services when the clients partner ask how this service can help, which of the following responses by the nurse is appropriate? a. This service offers psychological interventions during and after your wife's illness b. this service delivers meals and supplies to reduce your errands away from home c. It makes it possible for you to have some time away from caring for your wife d. the clinician help reduce the severity of your wife's physical problems 19. A home health nurse is performing a safety assessment for a client home which of the following findings should the nurse identify as a safety hazard? a. The client has used tacks to secure the carpet on the stairs b. the client is stores cleaning supplies in a lock cabinet above his head c. the client bedside lamp is plugged in using an extension cord with two prongs d. the client's electrical cord is taped to the floor 20. A nurse from the labor and delivery unit is assigned to float to a medical surgical unit which of the following actions should the nurse take first? a. Clarify competencies with the medical surgical charge nurse b. inform the nursing supervisor of the lack of experience on the medical surgical unit c. Request orientation to the medical surgical unit d. refer to the assigned resource nurse regarding client assignments 21. A nurse is speaking with a visitor who asks a question about the status of a relative who is a client on the unit, which the following responses by the nurse is appropriate? a. please ask your relatives about this because I cannot share information about her b. I am not talking care of your relative today, so I don't have the latest information c. let me check your relatives’ medical records to see how she's doing d. I will have your relatives nurse come in talk to you about her care 22. A nurse is supervising an assisting personal (AP) who is feeding a client who has dysphagia which of the following actions by the assistant personal (AP) should the nurse identify as correct techniques? a. Withholding fluids until the end of the meal b. instructing the client to place her chin towards her chest when swallowing c. elevating the head of the client’s bed to 30 degree during mealtime d. providing a 10-minute rest period prior to meals 23. A newly licensed nurse realizes that she administered Metoprolol 25 MG PO to the wrong client. Where should they follow in action should the nurse preform first? a. Call the provider b. inform the nurse manager c. complete an incident report d. measure the client’s vital signs 24. A nurse manager is reviewing isolation guidelines with a newly licensed nurse which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines? a. I will instruct visitors to wear a mask when visiting the client who is on contact precaution b. I will have a client who is on an airborne precaution wear a mask when out of the room c. I will place a client who has compromise immunity in a negative pressure airflow room d. I will wear an N 95 respirator mask when caring for a client who is on droplet precautions 25. A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse a an assistant personal which of the following tasks should the nurse assign to the LPN? a. Reinforcing dietary teaching with a client who has heart disease b. Accompanying a client who just had a wound debridement to physical therapy c. providing postmortem care for a client who had just died d. obtaining a urine specimen from an older adult client 26. A nurse in the emergency Department is assessing clients who have been triage using the triage tag system following a hurricane disaster which of the following client should the nurse assess first? a. A client who has a yellow tag b. a client who has a green tag c. a client who has a red tag d. A client who has a black tag 27. A nurse enters a client room and notices a small fire in the bathroom trash can, the nurse removes the client from the room why should they follow in actions should the nurse take next? a. activate the fire alarm b. remove all clients from the unit c. close the fire doors and the doors to the client’s rooms d. extinguish the fire 28. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure, which of the following findings indicates wound healing? a. deep red color on the center of a client's wound b. Erythema on the skin surrounding a client wound c. inflammation noted on the tissue edges of a client's wound d. increase in sanguineous exudate from the clients wound 29. A nurse enters the room of a client who is unconscious and finds that the son is reading her electronic medical records from a monitor located at the bedside which of the following actions should the nurse take first? a. Report the possible violation of client confidentiality to the nurse manager b. complete an incident report regarding the breach of client’s confidentiality c. recommend to his son to meet with the provider to get information about his mother's condition d. log out the computer so that the client's son is unable to view his mother's information 30. A nurse is providing information to a client about advance directives the nurse should explain that advance directives include which of the following? a. Information regarding organ donation b. a form with directions for contacting next of kind c. instructions regarding treatments the client desires or does not desire d. information regarding the disposition of the client's body upon death 31. A nurse witnesses a coworker not following facility procedure with discarding the unused portion of control substances, which of the following actions should the nurse take? (select all that apply) a. File an anonymous report of the incident to the nurse manager b. identify all witnesses to the incident c. request that the co-worker complete an incident report d. document a factual account of the incident e. submit an incident report to the risk management 32. A nurse on a medical surgical unit is caring for four clients, the nurse should recognize that which of the following clients is the highest priority? a. a client who is post-operative following it laminectomies 4 hours ago in unable to void b. A client who has peripheral vascular disease and has an absent Pedel pulse on the right foot c. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy d. a client who has MRSA and has an axillary temperature of 38C (101 F) 33. A Charge nurse is planning to evacuate clients on the unit because there is a fire on another floor. Which of the following clients should the nurse evacuate first? a. A client who is 1-day post-operative following thoracic surgery and has a chest tube b. A client who is confused and restrained for safety c. A client who is receiving IV chemotherapy and is ambulatory d. A client who is in Bucks traction for a hip Fracture 34. A nurse is caring for a group of clients who are receiving physical therapy. Which of the following information regarding a client should the nurse report to the physical therapist? a. A client has a Hemoglobin of 5g/DL b. A client has a new diagnosis of colorectal cancer c. A client has opioid-induced constipation d. A client has a prescription for a clean-catch urine test 35. A charge nurse is evaluating the implementation of infection control measures by unit nurses when caring for clients who are Clostridium difficile. The charge nurse should intervene for which of the following actions by a unit nurse? a. Places the client in contact precautions b. Cleans contaminated equipment with bleached- based solutionc. Uses Alcohol-based hand sanitizer after removing gloves d. Wears goggles when emptying the bedpan of liquid stools 36. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the following actions should the nurse take? a. Apply an antiviral cream to lesions b. Instruct the client to use condoms until the treatment is completed c. Initiate contact precautions d. Report the infection to local health department 37. A charge nurse is teaching a newly licensed nurse about hazardous and infectious materials. Which of the following situations should the nurse include as a safe handling technique? a. A nurse places a mask on a client with tuberculosis before transport to the radiology department. b. A nurse removes her gown after leaving the client’s room c. A nurse cleans up a blood spill with hydrogen peroxide d. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen 38. A client who is unconscious and has extensive internal injuries arrives via ambulance tothe ED. The staff cannot reach the client’s family. Which of the following permits the staff to proceed with the emergency surgery? a. Implied consent b. Good Samaritan Act c. Living will d. Nonmaleficence HESI LEADERSHIP Client has a living will that declines the use of artificial enteral nutritionreview the clients request with the family school-age child whose family is homeless child has red fissures at the corners of the mouth increased rate of client med errorsinform staf f of the penalties committee that is revising the policy for client dischargedetermine goals and objectives dilemma is referred to the ethics committee assist in weighing the options involved in the decision fire on the unit assist clients who are in immediate danger who reports vomiting and diarrhea for the past 6hrs serum potassium client rights should the nurse address at the orientation -respect and dignity -refuse meds -leave regardless -fully informed of their health admitting clients following an earthquakesucking chest wound nurse manager teaching about confidentiality requirements to the staffchange of shift report can be given at bedside newly licensed nurse perform a sterile dressing change on client who has centralvenous catheter pick up the first sterile glove 3 days post op following open heart surgeryclients level of consciousness Upgrade to remove adsOnly $0.99/month in-service for group of nurses caring for clients following stem cell transplantspositive-pressure air flow newly licensed nurse perform a routine abdominal assessmentplace the client in a dorsal recumbent postioin nurse is supervising the care of several clients nurse is photocopying their assigned clients dx tests discharge upon following hip arthroplastylength of clients stay terminal illness and voices concern about performing self carecase manager will coordinate the resources you willl need AP tells charge nurse that is unfair that they have to take care of all the clientsincontinent I delegate tasks to personnel based on their job descriptions client who is scheduled for outpatient surgery ask the client to explain the procedure that is being performed expressive aphasia procedure that does not require written informed consent staff nurse's behavior has changed over the past few weeks frequent use of restroom conflict is affecting the functioning of the unit explore alternative solutions to address unit workflow Upgrade to remove adsOnly $0.99/month tubal ligation and reports being uncertain discuss the client's feelings about the procedure implementing a plan to decrease the rate of pressure injuries in a long term carefacility compare data from client records regarding skin integrity nurse is caring for four clients a client who has a femur fracture wheelchair with a group of assistive personnel raise the footplates of the wheelchair before transferring should the charge nurse identify as demonstrating sterile techniquethe nurse places the sterile package with the top flap time-management skills group tasks that are in the same location newborn who requires apnea monitoring at home home health cancer that has metastisized gather info about palliative care no orthopedic experience client who had right above-the-knee amputation 24hr ago client is seeking drugs and is not in distressclients are the experts on their own pain Upgrade to remove adsOnly $0.99/month client who requests pain medicationfidelity client requests to be transferred to another unitask the client to verbalize their expectations stroke and now has left sided weaknessadvise the client to install grab bars poor attendance at monthly staff meetings explore the reasons that staff are not attending meetings increase in UTI on the unit perform a chart review to gather data about the clients verify that the client has given informed consent prior to which of theprocedures? receiving moderate sedation statements from the AP indicates the client the nurse should assess first?the client who had an indwelling urinary catheter following tasks should the nurse assign to the LPN? provide an enteral feeding to a client who has Crohns disease experiencing life-threatening injuries identify stable clients for transfer to a surgical unit mental health unit is teaching a newly licensed nurse about client rightsclients on a mental health unit can refuse their meds Upgrade to remove ads Only $0.99/month pulmonary tuberculosiswear an N95 I want to skip this dose of meds inform the client of the consequences of refusing the meds med surge unit is caring for four clients. priority? client who has peripheral vascular disease accommodate new bariatric services -role model a positive approach -encourage staff inter-professional conference for a client who is 3 days post opclient refuses to attend physical therapy client who does not have advance directive provide the client with info about advance directives tasks should the nurse plan to delegate to an APintake and output ventilator-associated pneumonia notify the quality improvement team looking at EM for a celebrity client on another unit remind the staf f members that this is a breach of confidentiality extra cranial-intracranial bypass discuss the clients concerns about having the surgery Upgrade to remove adsOnly $0.99/month remove a clients indwelling urinary catheter review the AP skill competency checklist client following a total hip arthroplasty inform the AP of the clients weight-bearing status inserted central catheters in the ICUstate nurse practice act NPA daily visits and receives lab results for four adult clientsplatelets 100,000/mm3 arrived late to work multiple times over the past several weeks -schedule meeting with the nurse -written reprimand -suspension -termination total knee arthroplasty and speaks a different languageinterpreter nurse reflects effective communication regarding delegation of a task to an APcheck urinary output at 1100 for John Doe difficulty buttoning their clothesoccupational therapist HESI LEADERSHIP Original manager confronts a nurse with smell of alcohol on her breath. which action totake? set up formal meeting within 24 hr client requests pain med. nurse fulfills a promise to return with med in 15 min.nurse demonstrates which ethical principle fidelity adverse effects after a new med. which communication tool for complicationSBAR urgent care nurse pain assessment not to policy. take which actionreport this issue to the nurse manager potassium 3.2, been paging provider for 1hr to report. which intervention nextnotify nursing supervisor assign AP which task suction a clients trach informed consent prior to receiving moderate sedation pt has dnr. AP understands when states... "i will call for the clients nurse to come to the room if i cannot detect a pulse" charge nurse orienting new nurse. understands when.. "after i finish with the printout of my assignment i will put it in the shredder nurse planning DC for stroke. which intervention advise client to install grab bars in her bathroom at home frayed cord of infusion pump. take which actionReport the pump... long term facility transferring to acute care facility. include what info in paperwork list of current medications Upgrade to remove adsOnly $0.99/month charge nurse supervising several clients which require intervention studen tnurse photocopying... nurse caring for four clients. which priorityclient with PVD and absent pulse staff not answering call light promplty ask the client to verbalize his expectations planning care for client who has dementia placing client in a room near the nurses station UTI quality improvement establish best practice guidelines for reducing the incidence of UTIs AP qualified review the APs skill competency checklist change of shift 4 clients miss graves needs pain reassed tubal ligation, uncertain discuss the clients feelings about the procedure committee for discharge determine goals and objectives mental health mechanical restraints i should request the provider to examine the client within 1 hour of applying mechanical restraints Upgrade to remove adsOnly $0.99/month arguing about restock i would like for you to approach the ap to resolve the problem time management skills groups tasks that are in the same location no ortho experience client who had a right above knee amp 24 hr ago safe use of wheelchair raise footplates before transferring external disaster plan activated identify stable patients for transfer to surg unit smoke from wastebasket transported client to hallway charge managing conflict... you always complete your work on time and do a great job..... caring following stem cell place clients in positive pressure airflow rooms decrease rate of pressure ulcers compare data from clients records regarding skin integrity sterile dressing change the nurse places the sterile package with the top flap opening away from her Upgrade to remove adsOnly $0.99/month reflects intrapersonal conflict im not sure whether i want to apply for unit manager or start a family delegating unit short staffed. wound irrigationassign procedure to LPN outpatient surgery gave consent ask the client to explain the procedure that is being performed joint repacement surgeryadvocacy planning daily work priorityassign client care to staff discharged with post op infection, PICC ensure that home infusion therapy has been arranged nurse receiving report on four clientsPotassium 6.5 difficulty buttoning her clothesoccupational therapy morning lab results, exhibit obtain a cap blood glucose reading nurse has arrived late issue informal verbal give nurse formal suspend without pay terminate employement Upgrade to remove adsOnly $0.99/month clinical pathway following hip arthroplastylength of clients stay abdominal pain admitted completing the clients initial admin assessment 18 yr old rhabdomyosarcoma the nurse states i can gather info about palliative care client rights understanding of teacing clients on mental health unit can refuse meds ER perfomring triage after MVC arm contusions and asym thoracic movement delegate to ap measuring I&O staff looking atEMR for celeb remind staff this is a breach of confidentiality COPD receiving oxygenan office chair oxygen tank on floorthrow rug over vinyl restraints to combative quick release tie to secure restraint 2 hr postop following cholerecheck the clients BP Upgrade to remove adsOnly $0.99/month right direction of communication tell me what time the client in 205 voids for the first time after cath removal four clients who's priority adult client femur fracture SOB poor attendence explore reasons staff are not attending breast cancer otions lets talk about benefits of each VAP notify quality improvement team cancer and vomits blood mop the floors with a bleach solution advance directives this means i have outlines my wishes for med treatments community health clinic communicable diseases. nationally infection disease chlamydia An RN has to teach the client initially but can delegate to an LPN.reinforcing the teaching An LPN can perform care .tracheostomy care Can an RN delegate to an LPN to perform suctioning?yes Can an RN delegate to an LPN to put in a urinary catheter?yes Can an RN delegate to an AP to feed a client not on swallow precautions?yes Is an RN allowed to delegate to an AP to collect a urine sample?yes A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required naloxone (narcan) for depressed respirations. Is this an appropriatetask for the AP? no An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse totake first? A. Call the client's provider B. Ask a staff member for assistance getting the client back in bed C. Inspect the client for injuries D. Ask the client why he got out of bed w/out assistance C. Inspect the client for injuries An RN on a med-surg unit is making assignments at the beginning of the shift.Which of the following tasks should the nurse delegate to the LPN? A. Obtain vitals for a client who is 2 hr postop following a cardiac cath B. Administering a unit of PRBCs C. Instructing a client in the performance of wound care D. Developing a plan of care for a newly admitted client A A nurse is caring for an older adult client who has left the unit for a radiology procedure. The client's son asks the nurse what med is being given to the client.Which of the following is an appropriate response by the nurse? A. "I am sorry, but that is information you will need to ask your mother or her doctor." B. "Your mother is taking famotidine (Pepcid) for the ulcer & lorazepam (Ativan)for anxiety." C. "You will need to ask the charge nurse for that info." D. "Don't worry. We will give your mother all pertinent info before discharge." A. A nurse works in a mental health facility that uses a case management nursing model to provide care. The nurse should recognize that which of the followingdescribes a case management approach to care? A. A nurse provides total care for several clients B. Collaboration between disciplines creates a multidisciplinary care plan for each client. C. The focus of care is on detecting disorders at an early stage. D. The team leader assigns care for a group of clients B A nurse overhears a client talking with an attorney, reporting physical abuse, useof restraints & denial of meals. What action should the nurse take? A. Report the conversation to the nurse manager to allow for follow-up investigation. B. Question the client about the allegations to identify staff who were allegedly involved. C. Ignore the conversation unless the client brings it to the attention of the nurse. D. Recognize this as a privileged communication that cannot be discussed w/anyone. A Upgrade to remove adsOnly $0.99/month A nurse manager is planning a department meeting to discuss client advocacy. Which of the following situations should be included in the discussion? Select allthat apply. A. Discussing treatment options w/a client who was pancreatic cancer B. Notifying the surgeon when a client signing a surgical consent form has questions about the procedure C. Helping a client make a list of questions she would like to ask the provider D. Clarifying the dosage of a med prescribed for an older adult client who has impaired liver function E. Carrying out end-of-life wishes outlined in the living will of an older adultB, C, D, E A nurse is assessing a client's negligible progress in following a weight loss program. Which of the following is a likely reason the client was unable to achievea short-term goal established during the planning phase of the nursing process? A. The goals were realistic & formulated w/client input. B. The underlying problem behind past weight gain was misidentified. C. The implementation of the plan used flexibility in following the nursing actions D. The nurse obtained objective & subjective data during the assessment.B A nurse has prepared an IM injection for a client who is preoperative, when another client suddenly calls for assistance. The nurse asks an LPN to give the injection since an AP is waiting to take the client to surgery. Which of the followingis an appropriate action by the LPN? A. Prepare a new syringe for the client who is preop B. Give the prepared med to the client who is preop C. Help the client requesting assistance so the nurse can give the prepared injection D. Report this request to the charge nurse C A new charge nurse on a busy surgical unit notes a high degree of tension amongthe nursing staff. Which of the following should be the initial method used for resolving this issue? A. Work w/the nurses to identify stressors B. Hire additional staff to decrease the work load C. Make relaxation tapes available to staff to help decrease stress D. Reassess the situation after the nurses have become accustomed to the new charge nurse A A nurse on a long-term care unit finds that a client receiving dialysis was administered captopril (capoten), which was not prescribed for the client. Inwhich order should the nurse take the actions listed? Complete an incident report. Contact the risk manager. Instruct the client to call for assistance when getting out of bed. Measure the client's vital signs Notify the provider 1. Measure the client's vitals 2. Instruct the client to call for assistance when getting out of bed 3. Notify provider 4. Complete an incident report 5. Contact the risk manager A nurse is caring for a group of clients on a med surg unit. Which of the followingtasks should the nurse delegate to the assistive personnel (AP)? Select all that apply. A. Collecting a stool specimen B. Providing instructions about using a spirometer C. Measuring oral intake D. Providing postmortem care E. Changing a dressingA, C, D A nurse on a med surg unit is planning care of assigned clients. Which of thefollowing clients should the nurse assess first? A. A client who is newly admitted & is to have an indwelling urinary catheter inserted B. A client who has kidney stones & reports flank pain 6 out of 10 C. A client diagnosed w/early-stage chronic kidney disease w/a serum creatinine level of 2.0 mg/dL D. A client who has a cast newly applied on his forearm and reports tingling of his fingers D An RN working w/an LPN is planning client care assignments. Which of thefollowing tasks should the nurse delegate to the LPN? A. Performing tracheostomy suctioning for a stable client B. Performing an admission assessment of a client who is preop C. Initiating the referral of a client to hospice D. Interpreting a client's digoxin level A A client is prescribed morphine sulfate IM. Which of the following should thenurse recognize as a requirement for governing controlled substances? A. Delegate med admin to a RN B. Ask another nurse to observe disposal of unused med C. Request another nurse to validate admin of the med D. Observe the LPN admin the med B An older adult client who has early Alzheimer's disease is living w/an adult childwho is employed part-time but is committed to keeping her parent at home. Which of the following options is appropriate for the nurse to discuss w/the client& family at this time? A. Hospice care B. Adult day care C. An assisted-living facility D. Long-term care facilityB A nurse is overheard telling other nurses that the unit manager gives preferentialtreatment to nurses on the night shift. Which of the following approaches by the unit manager reflects an assertive response to resolution of this conflict? A. Understand that the vocal nurse is misinformed & take no action. B. Assign the vocal staff nurse to work the night shift to allow direct experience w/the night shift. C. Meet one-on-one w/the vocal staff nurse to discuss the concerns raised D. Confront the staff nurse during the next unit meeting regarding her statementC A nurse is caring for a group of clients on a medical unit. Which of the following isthe priority finding the nurse should report to the provider? A. A client receiving metoclopramide (Reglan) reports diarrhea B. A client receiving tamsulosin (Flomax) reports feeling dizzy C. A client receiving cephalexin (Keflex) reports dyspnea D. A client receiving erythromycin (E-Mycin) reports epigastric painC A nurse is caring for a client who has recently been prescribed lithium carbonate (Eskalith). Which of the following is the priority assessment finding for this client? A. Fine hand tremors B. Weight gain of 2.7 kg (6 lb) C. Report of nausea D. Poor motor coordination D A nurse manager is reviewing the function of "Code of Ethics for Nurses with Interpretive Statements" during a staff meeting. The nurse manager recognizesthat this document is: A. legally binding B. mandatory for the practice of nursing C. a description of requirements for licensure D. a guide for professional actions D. A nurse manager finds an increased incidence of health-care associated infections(HAIs) on a long term care unit. Which of the following is the priority action the nurse manager should take to address the problem? A. Monitor the staff's hand hygiene techniques B. Hold a mandatory in-service about hand hygiene & infection rates C. Require nurses to take an online course on HAIs D. Conduct a chart review to gather data about clients who developed HAIs D A nurse manager is about to write a 2 month performance appraisal for a newlygraduated nurse. Which of the following factors should the nurse manager take into consideration when planning a performance appraisal interview for this nurse? A. The written appraisal & interview should sound friendly & be informal B. No one except the nurse manager should have input regarding the nurses's appraisal C. A nursing administrator who does not know the nurse should conduct the interview to promote fairness D. The nurse should have a copy of performance standards before the appraisal interview D A nurse working at a rehab facility attends an interdisciplinary team meeting for aclient who has had a left hemispheric stroke. Which of the following members ofthe interdisciplinary team should the nurse expect to contribute to the plan of care? Select all that apply. A. Nurse B. Occupational therapist C. Speech therapist D. Physical therapist E. Respiratory therapist A, B, C, D A nurse is writing a goal for a client's reaction following the admin of a med. Which of the following phases of the nursing process should the nurse modify? A. Planning B. Evaluation C. Analyzing D. Assessment A The actual writing of an expected outcome is done in the planning phase of thenursing care plan. A charge nurse on a med surg unit is assigning client care to an RN and an LPN.Which of the following tasks should the nurse assign to the RN? Select all that apply. A. Performing colostomy care B. Administering blood to a client C. Developing a plan of care for a client D. Calculating a TPN flow rate E. Checking nasogastric tube patency B, C, D A nurse manager is providing info about the audit process to members of the nursing team. Which of the following statements should the nurse manager include? Select all that apply. A. A structure audit evaluates the setting & resources available to provide care B. An outcome audit evaluates the results of the nursing care provided C. A root cause analysis is indicated when a sentinel event occurs D. Retrospective audits are conducted while the client is receiving care E. After data collection is completed, it is compared to a benchmark A, B, C, E A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following will provide the most relevant inforegarding the efficacy of the procedure? A. Frequency w/which the procedure is performed B. Client satisfaction w/performance of procedure C. Incidence of complications r/t procedure D. Accurate documentation of how the procedure was performedC A nurse manager has received a performance appraisal from the unit manager.Which of the following actions by the unit manager requires intervention? A. The evaluation was conducted in the unit manager's office B. Data that was collected for the previous 12 months was presented C. Verbal concerns provided by a staff member were incorporated into the data D. The nurse was asked to review the performance appraisal & complete a self- evaluation C A nurse is preparing to transfer an older adult client who is 72 hr postop from a surgical procedure to a long term care facility. Which of the following should thenurse include in the transfer report? Select all that apply. A. Type of anesthesia used B. The client's advance directives status C. The client's vital signs on day of admission D. The client's medical diagnosis E. Need for special equipment B, D, E A nurse is participating in an interprofessional conference for a client who has a recent C6 spinal cord injury. The client worked as a construction worker prior to his injury. Which of the following members of the interprofessional team should also participate in planning care for this client? Select all that apply. A. Physical therapist B. Speech therapist C. Occupational therapist D. Psychologist E. Vocational counselor A, C, D, E A nurse manager is working with a committee of nurses whose task is to update the policies for new employee orientation. The nurse manager directs the team tocollect as much data as possible & recommend several options. Which of the following decision-making styles is being demonstrated by the nurse manager? A. Decisive B. Flexible C. Hierarchical D. Integrative D. A nurse who has just assumed the role of unit manager is examining her skills ininterprofressional collaboration. Which of the following actions support interprofessional collaboration? Select all that apply. A. Use aggressive communication when addressing the team B. Recognize the knowledge & skills of each member of the team C. Ensure that a nurse is assigned to serve as the group facilitator for all interdisciplinary meetings D. Encourage the client & family to participate in the team meeting E. Support team member requests for referral B, D, E A nurse is caring for a client who is being prepared for surgery. The client hands the nurse info about advance directives & states, "Here, I don't need this. I am too young to worry about life-sustaining measures & what I want done for me." Whichof the following actions should the nurse take? A. Return the papers to the admitting dept w/a note stating that the client doesn't wish to address the issue at this time. B. Explain to the client that you never know what can happen during surgery & that he should fill the paper's out "just in case." C. Contact a client representative to talk w/the client & offer additional info about the purpose of advance directives D. Inform the client that the surgery cannot be conducted unless he completes his advance directives forms C A nurse is serving as a preceptor to a newly licensed nurse & is explaining the roleof the nurse as advocate. Which of the following situations illustrates the advocacy role? Select all that apply. A. Verifying that a client understands what is done during a cardiac catheterization B. Discussing treatment options for a terminal diagnosis C. Informing members of the health care team that a client has DNR status D. Reporting that a health team member on the previous shift did not provide care as prescribed E. Assisting a client to make a decision about his care based on the nurse's recommendations A, C, D A nurse manager is providing info to the nurses on the unit about ensuring clientrights. Which of the following outlines the rights of individuals in health care settings? A. American Nurses Association Code of Ethics B. HIPAA C. Patient Self-Determination Act D. Patient Care Partnership D A nurse is reviewing a client's health care record & discovers that the client's DNRorder has expired. The client's condition is not stable. Which of the following actions should the nurse take? A. Assume that the client does not want be resuscitated, & take no action if she experiences cardiac arrest B. Write a note on the front of the provider order sheet asking that the DNR order be reordered C. Anticipate that CPR will be instituted if the client goes into cardiopulmonary arrest D. Call the provider to determine whether the order should be immediately reinstated D A home health nurse is assessing the safety of a client's home. Which of the following factors may increase the client's risk for falls? Select all that apply. A. History of a previous fall B. Reduced vision C. Impaired memory D. Takes rosuvastatin (Crestor) E. Wears house slippers F. Kyphosi sA, B, C, E, F A client is brought back to the unit after a total hip arthroplasty. The client is confused, is moving his leg into positions that could dislocate the new hip joint, &repeatedly attempts to get out of bed. Which of the following actions should the nurse take? Select all that apply. A. Apply arm & leg restraints immediately B. Get an order from the provider C. Have a family member sign the consent for restraints D. Use a square knot to secure the restraints to the bed frame E. Ensure that only one finger can be inserted between the restraint and the clientA, B, C A nurse is observing a newly licensed nurse & an AP pull a client up in bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates aneed for further education? A. The nurse spreads his legs apart B. The nurse uses his body weight to counter the client's weight C. The nurse's feet are facing inward, toward the center of the bed D. The nurse uses the muscles in his arms to lift the client off the bed using the drawsheet C An AP reports that a client's finger-stick blood glucose reading 30 min before lunch is 58 mg/dL. The client's morning finger-stick blood glucose was 285 mg/dL.The client is asymptomatic for hypoglycemia, & his next dose of insulin is scheduled to be administered at this time. Which of the following actions should the nurse take first? A. Recalibrate the glucometer, & recheck the client's blood glucose B. Have the lab draw a stat serum glucose C. Inform the AP to give the client 120 mL of orange juice D. Administer insulin as prescribed A A nurse discovers that a client was administered an antihypertensive med in error.Number the following actions in the appropriate sequence that the nurse should follow. A. Call the client's provider B. Monitor the client's vitals C. Notify the risk manager D. Complete an incident report E. Instruct the client to remain in bed until further notice 1. B 2. E 3. A 4. D 5. C - Monitor the client's vitals. - Instruct the client to remain in bed until further notice. - Call the client's provider - Complete an incident report - Notify the risk manager A nurse manager is explaining the use of incident reports to a group of nurses inan orientation program. Which of the following statements should the nurse manager include? Select all that apply. A. A description of the incident should be documented in the client's health carerecord B. Incident reports should not be shared w/the client C. Incident reports include a description of the incident & actions taken D. A copy of the incident report should be placed in the client's health care recordE. The risk management dept. investigates the incident A, B, C, E [Show More]

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