Leadership 204 Leadership Hesi Review- Fortis College

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Leadership Hesi Review 1. The charge nurse, along with one nurse, two practical nurses (PN), a unit secretary, and two unlicensed assistive personal (UAP), is caring for 24 clients on a medical surgic... al unit. Which task is best for the charge nurse to assign to the nurse? o The admission assessment of a client diagnosed with bacterial pneumonia o The subclavian dressing change on a client diagnosed with inflammatory bowel disease o Transcription of the healthcare provider’s treatment plan for a client transferred from a critical care unit o The insertion of a foley catheter for a client diagnosed with septicemia 2. The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be retrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager? o Close the door to the room to avoid disturbing other clients in nearby rooms. o Advise the staff nurse to remove the restraints from the client’s wrists o Contact the healthcare provider to ensure that a prescription for restraints was written o Determine if the client has a PRN prescription for an antianxiety agent 3. After having coronary artery bypass surgery, a client develops a deep venous thrombosis in the left leg. Which nurse should be responsible for coordinating the progression of the client’s care? o Risk management nurse o Nurse case manager o Cardiology unit supervisor o Adult nurse practitioner 4. A client is transferred to the surgical unit following a strangulated inguinal hernia repair. The post anesthesia care unit nurse reports the total intake and output that occurred during surgery, the sedation reversal agent, and two episodes of emesis post extubation. Which additional information should the nurse provide to complete this report? o Soft abdomen, absent bowel sounds, no bleeding on dressing o Peripheral pulses present with full range of motion of both legs o History of vomiting at home for 3 days prior to surgery o Refuses to take ice chips for complaints of dry mouth 5. When assessing a client who is returned to the unit following a left nephrectomy, the nurse notes a small amount of bloody drainage at the drain site. Which intervention is most important for the nurse to include in this client’s plan of care? o Document temperature every four hours o Turn, cough, deep breath o Provide sips of water and ice chips o Monitor urinary output hourly 6. The nurse assigns collection of a sputum specimen to an unlicensed assistive personnel (UAP). Before delegating this task to the UAP, which action is most important for the nurse to implement? o Verify the UAP has read the procedure for collection of sputum specimen. o Determine if the UAP received training to collect sputum specimen. o Assess the client’s willingness to allow the UAP to collect the specimen. o Review the institutional policy for delegation with the nursing supervisor. 7. A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment? o A 2-year-old girl with a history of a “cold.” Today she is tugging on her ear and has a fever of 102 F (38.9 C). o A 42-year-old male who hurt his back while lifting yesterday. Today he has non-radiating, low- pain rated at 10 on a scale of 1 to 10. o A client at 38-weeks gestation who today noted a small amount of bright red blood on the toilet paper after passing stool. o A 21-year-old with a history of a kidney transplant. Today the client reports “flulike” symptoms with a fever of 100.4 F (38 C). 8. The nurse hears a newly employed unlicensed assistive personnel (UAP) who is working in a long-term care facility calling the adult residents “honey” and “dearie.” What is the best action for the nurse to take? o Role model the correct approach for addressing the residents. o Ask the long term care facility supervisor to rebuke the UAP. o Meet with the UAP to discuss respectful client care strategies. o Call a staff meeting to encourage more professional behaviors. 9. The nurse is planning care for a client who is experiencing acute pain. Which intervention can be implemented by the unlicensed assistive personnel (UAP) in providing personal care for this client? o Guided imagery o Patient-controlled analgesia o Distraction o Biofeedback 10. The nurse calls a surgeon about a male client who is having abdominal pain after a bowel resection. He received hydromorphone 2 hours ago and is now requesting additional pain medication. Vital signs include temperature 97.8 F (36.6 C), heart rate 112 beats/minute, respirations 24 breaths/minute, and blood pressure is 98/62 mmHg, which is lower from previous reading one hour ago. The client has a history of chronic atrial fibrillation and takes clopidogrel, which was continued until one day prior to surgery. The nurse recommends that the surgeon see the client immediately to evaluate the situation. What information makes this report complete? o Nasogastric suction is draining bile-colored secretions o Lungs are clear bilaterally and oxygen saturation is 97% o The abdomen is rigid, tender to touch, and distended o Client’s [Show More]

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