HESI RN EVOLVE Management Practice Exam

HESI RN EVOLVE Management Practice Exam The nurse is preparing assignments for the day shift. It is most important that the client with which diagnosis and description is assigned to a RN? A. Menorrhagia: 24 hrs post vaginal hysterectomy. B. MI: 4-days post infarction, transferred from ICU yesterday. C. Depression: Admitted during the night following a suicide attempt with an OD of Tylenol D. Pneumonia: A 4 yo who is receiving IB antibiotics C. Depression: Admitted during the night following a suicide attempt with an OD of Tylenol Rationale: Requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. Additionally, Tylenol is extemely hepatotoxic and careful assessment is essential. During report, the charge nurse informs a nurse that she must work on another unit. The nurse begins to sigh deeply and tosses about her belongings as she is preparing to leave, making it known that she is very unhappy about having to "float." What is the best immediate action for the charge nurse to take? A. Continue with report, and talk to the nurse about the incident at a later time. B. Ask the nurse to call the supervisor to see if she can be reassigned. C. Stop report and remind the nurse that all staff must "float" at some time. D. In the presences of other staff members, inform the nurse that her behavior is inappropriate. A. Continue with report, and talk to the nurse about the incident at a later time. Rationale: This is the best immediate action. At a later time the charge nurse should discuss with the nurse in private her inappropriate conduct. A 15yo sexually active girl diagnosed with PID is admitted to the hospital with a temp of 101.6 F and purulent vaginal discharge. She has no insurance and tells the nurse she enjoys small children. Which room should the nurse assign this client? A. A semi-private room with a 4yo girl who is currently receiving chemotherapy. B. A semi-private room with an older adolescent girl who had surgery yesterday. C. A room close to the nurse's station. D. A private room. D. A private room. Rationale: Despite the fact that the client has no insurance and enjoys small children, she in infected and should be placed in a private room. The client is not acutely ill and does not need to be assigned next to the nurse's station. The RN and UAP are working together to provide care for a bedfast client needing total care, medications, and Foley catheter irrigation. How should the RN assign the client's care? A. UAP: Personal care, catheter irrigation, I&O. RN: Medications. B. UAP: Personal care. RN: Medications, catheter irrigation, I&O. C. UAP: Catheter irrigation, I&O. RN: Medications. Both provide personal care. D. UAP: Personal care, I&O. RN: Catheter irrigation, medications. D. UAP: Personal care, I&O. RN: Catheter irrigation, medications. Rationale: The RN is reponsible to med administration and sterile procedures such as catheter irrigation. The UAP is qualified to provide personal care and measure I&O. The charge nurse assigns the care of a client with diabetes who has hyperglycemia to a PN. In supervising the PN, what is the charge nurse's most important action? A. Decide which sliding scale insulin dose should be administered. B. Obtain the blood sugar results via skin puncture and glucometer. C. Notify the healthcare provider of the daily serum glucose results. D. Confer with the PN about any manifestations the client is exhibiting. D. Confer with the PN about any manifestations the client is exhibiting. Rationale: The nurse's expertise in needed to perform a critical assessment, such as assessing the client for signs of hyperglycemia and to supervise the ongoing monitoring of the client by the PN. A RN is caring for several clients on a progressive care "step-down" unit. After assessing the clients, which clerical task should the nurse assign to a UAP? A. Chart pulse ox readings and type of breath sounds auscultated in the medical record. B. Record the presence of blood-tinged urine and the hourly Foley output on the flow sheet. C. Document the type and amount of drainage on a new surgical dressing in the progress note. D. Transcribe the vital signs from a unit worksheet to the individual graphic page in the client charts. D. Transcribe the vital signs from a unit worksheet to the individual graphic page in the client charts. Rationale: Recording the VS on the graphic record does not entail assessment or evaluation of the findings, so the UAP may perform. RNs may not delegate assessment or documentation responsibilities to UAPs. RNs must complere assessment activities and record findings in the medical record. Which situation requires intervention by the nurse who is caring for a terminally ill client in a hospital? A. The case manager notifies the family that the critical pathway requires transfer to a hospice facility. B. The case manager notifies the social worker of the client's financial needs r/t hospice care. C. The social worker describes the client's feelings of the grief to the spiritual counselor. D. The social worker provides info about long-term care facilities to the client. A. The case manager notifies the family that the critical pathway requires transfer to a hospice facility. Rationale: Critical pathways provide care guidelines, rather than required methods of care. The nurse should intervene to ensure that the client and family are aware of options available. The UAP reports morning vital signs to the primary nurse. Which client should the nurse assess first? The client who is A. diagnosed with myxedema with a temp of 96.8 F. B. one-day postop abdominal surgery with a pulse of 104. C. diagnosed with HTN and has a BP of 154/94. D. diagnosed with pneumonia and has a respiratory rate of 26. D. diagnosed with pneumonia and has a respiratory rate of 26. Rationale: The normal RR is 12-20, so a client with respiratory compromise (pneumonia) who has increased RR should be assessed immediately. A, B, and C are expected for patient condition. A female client is receiving an enteral feeding via nasogastric feeding tube. The daughter reports to the charge nurse that her mother is coughing vigorously and sounds congested. Which staff member should the charge nurse ask the check on the client? A. RN who is admitting a new postop client to the unit. B. PN who is giving routine medications. C. PN who is talking with anxious family members. D. RN who is entering nursing notes at the computer. D. RN who is entering nursing notes at the computer. Rationale: The RN who is entering notes is working on a task that has less priority than A. The client requires advanced, problem solving assessment skills and the RN is best qualified to assess the client's lungs, position of NGT, and the possibility that the feeding tube has moved or kninked, allowing the tube feeding to enter the lungs. The charge nurse, along with two RNs, one PN, and one UAP, is working in an ED. What activity should be assigned to the UAP? A. Monitor a client with mid-sternal chest pain, nausea, and vomiting. B. Give instructions to the EMS about a patient being transferred to a nursing home. C. Transport a client diagnosed with septicemia to the medical unit. D. Obtain the history from a female client who presents in early labor. C. Transport a client diagnosed with septicemia to the medical unit. Rationale: The client with septicemia could be safely transported by the UAP to the medical unit. A is unstable and should be monitored by an RN. EMS need transfer instructions from the RN. The charge nurse working in a long-term care facility is informed by the LPN that a client's son in unhappy with the care his mother is receiving. What action should the nurse take first? A. Ask the family member to come to the nurses' station to discuss the concerns. B. Provide the son with a complaint form and ask him to describe the situation. C. Discuss with the LPN the son's concerns about his mother's care. D. Notify the administrator of the long-term care facility about the son's discontent. C. Discuss with the LPN the son's concerns about his mother's care. Rationale: The nurse should first obtain info about the nature of the complaint and ske the LPN to describe the situation. A, B, and D may be implemented after. When the charge nurse is making assignments, which tasks can be assigned to an UAP? A. Perform a dressing change, oral suctioning, and admission of a client to the unit. B. Time contractions, determine FHR, and administer an enema to a client in early labor. C. Take vital signs, give a cleansing enema, and apply soft restraints to an older client. D. Irrigate a NG tube, collect a stool specimen, and measure I&O. C. Take vital signs, give a cleansing enema, and apply soft restraints to an older client. Rationale: All of the tasks in C can be assigned to a UAP. Tasks that involve assessment should be assigned to PNs or RNs. Upgrade to remove ads Only $3.99/month The charge nurse is assigning a room for a newly-admitted client, diagnosed with acute Pneumocystis carinii pneumonia, secondary to AIDS. Which room would be best to assign to this client? A. A private room fully equipped with an outside air ventillation system. B. A semi-private room shared with a bed-ridden elder who would enjoy the company. C. A semi-privare room with a bed available nearest to the bathroom. D. A semi-private room that does not have a client in the other bed at this time. D. A semi-private room that does not have a client in the other bed at this time. Rationale: This room can be easily blocked to create a prive room should the client require isolation measures d/t the pneumonia. AIDS alone does not affect room assignment. 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? A. A 10yo with asthma who is responding well to nebulizer treatments. B. A 3-week-old infant who is nursing and was brought in because he had a fever. C. A 4yo receiving IV fluid for dehydration whose fluid bag is empty. D. A 6yo with Down syndrome who has been coughing productively. C. A 4yo receiving IV fluid for dehydration whose fluid bag is empty. Rationale: The child who is dehydrated needs care first. Not knowing how long the fluid bag has been empty, the nurse should hang a new bag, see if it flow, and if not, assess for infiltration. A is stable. B is not in acute distress. D is of less immediacy than C. The nurse is designing a program to control nosocomial infections on a geri unit of an acute care hospital. What strategy should be included in this plan? A. Do not allow those with influenze to be admitted to the unit. B. Require that all clients receive a pneumonia vaccine prior to admission. C. Ensure that sterile technique is followed when changing surgical dressings. D. Encourage clients to drink water to prevent UTIs. C. Ensure that sterile technique is followed when changing surgical dressings. Rationale: A nonsocomial infection is one that was not present or incubating at the time of admission, and using good sterile technique and medical asepsis helps to prevent this. A, B, and D are not specific to nosocomial infections. The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced PNs and one UAP who has worked on the unit for 10 yrs. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? A. 10 clients and 2 admissions to each PN. Have the UAP take all vitals and collect all I&Os. B. 10 clients to each PN. Have the UAP take vitals. The charge nurse take the 4 new admissions. C. 8 clients to each PN, 4 clients to the charge nurse, and the 4 admissions to the UAP. D. 8 clients to each PN, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP. B. 10 clients to each PN. Have the UAP take vitals. The charge nurse take the 4 new admissions. Rationale: Considering acuity, B is best. UAP is not qualified to conduct an admission assessment or take resposibility for total care of clients. An ER anticipates an influx of injured clients from a large motor vehicle collision on a major freeway. Which client should the triage nurse send to the trauma staff for immediate intervention? A. A young adult male with a suspected closed head injury who has no respiration despite having his airway repositioned. B. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway. C. A teen with a suspected fractured left leg whose respirations are 26, cap refill less than 2 sec, and able to follow commands. D. A young adult with a facial laceration that is controlled by pressure and whose respiratory rate, cap refill, and ability to follow commands are all WNL. B. An adult with a suspected intraabdominal bleed who was not breathing on arrival, but is currently responding since repositioning the airway. Rationale: Clients with life-threatening injuries and a respiratory rate >30 (B) are red tagged and recieve immediate treatment. Clients with catastrophic injuries (A) and no respiratory rate have minimal chance of survival and should be black tagged and receive no treatment. Clients whose injuries have systemic effects and complications, but whose respiratory rate, cap refill, and mental status are WNL (C) are yellow tagged and should receive treatment within 30-60 min. The "walking wounded" with no systemic complications (D) should be removed to a separate area and treatment can be delayed. Which pediatric client requires immediate intervention by the nurse? A. A 2yo with a 24 hr urinary output of 500 ml. B. A 3yo with several episodes of noctural enuresis. C. A 4yo with an easily palpable bladder and frequency. D. A 5yo with diuresis following furosemide (Lasix) administration. C. A 4yo with an easily palpable bladder and frequency. Rationale: These are indications of urinary retention, which requires immediate intervention. The nurse is caring for 4 clients on an ortho floor: 2 clients with total hip replacements, one client with total knee replacement, and one client with a fractured femur who is in skeletal traction. Which nursing task should the nurse delegate to the UAP? A. Adjust the setting on the CPM. B. Clean the skeletal traction insertion sites while performing a.m. care. C. Assist the client to ambulate for the first time after surgery. D. Change the linens for the client with skeletal traction. D. Change the linens for the client with skeletal traction. Rationale: The client cannot get out of bed, so the UAP should change the linens with the client in bed. PT or RN should implement A and C. B should not be delegated. The nurse is giving change-of-shift report for four clients in the emergency center and reports the client with a terminal disease has a living will and a DNR order on file Which client fits the criteria for a terminal illness? A. A 2yo child with esophageal burns from drinking drain cleaner who now has a g tube. B. 76yo female client with AD who is pacing the halls and trying to "go home." C. 52 yo male client who had a partial lobectomy and on a ventilator on the 2 postop day. D. 43 yo male with ALS who is refusing artificial nutrition or hydration. D. 43 yo male with ALS who is refusing artificial nutrition or hydration. Rationale: Terminal illness describes client's life expectancy as less than 6 mos without life-sustaining measures. D may not survive more than a few days after refusal of food and hydration. The nurse-manager is talking to a new nurse who is thinking about resigning before orientation to the unit is over. The nurse-manager explains that reality shock after graduation is common. Which explanation should the nurse-manager use to best describe reality shock to the new nurse? A. A realization that practice and education are not the same. B. A series of experiences to become an experienced nurse. C. A period of role adjustment from school into the work force. D. A phase the new nurses go through before changing jobs. C. A period of role adjustment from school into the work force. Rationale: Term used to describe the reaction experienced when one moves after several yrs of educational preparation, which occurs in a familiar, idealistic educational environment, into a new role in the work force where the expectations are not clearlt defined in a realistic setting. Which task should the nurse delegate to an UAP? A. Accompany the healthcare provider during client visits. B. Determine a client's response to pain. C. Observe a client's CVC site. D. Feed a client with minical dysphagia. D. Feed a client with minical dysphagia. Rationale: This is a basic client care measure within the scope of practice for a UAP. A, B, and C require assessment and analysis. Upgrade to remove ads Only $3.99/month The nurse receives report in the emergency center for four clients. Which client should the nurse assess first? A. A screaming child with a compound fracture of the wrist. B. A diabetic client with a laceration on the sole of the foot. C. A client experiencing SOB and dyspnea. D. A geri client with many new and old bruises noted. C. A client experiencing SOB and dyspnea. Rationale: Maslow's hierarchy of needs prioritizes oxygen and airway. During CABG surgery, a male client with a history of chronic tobacco abuse experiences a dramatic decrease in his oxygen sat. Subsequently, the client remains on a ventilator two days longer than anticipated. Which factor should the nurse consider when evaluation the client's progress? A. Goal. B. Variance. C. Standard. D. Outcome B. Variance. Rationale: A variance is any event that may alter a client's progress through the clinical pathway, sich as remaining on a ventilator for an additional 2 days. 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. An elderly client with end-stage cirrhosis who had a liver biopsy 8 hrs ago. B. A client scheduled for a femoro-popliteal bypass surgery tomorrow. C. A middle-aged client with acute diverticulitis and lower left quadrant pain. D. A female client with angina and ectopy noted on the tele monitor. B. A client scheduled for a femoro-popliteal bypass surgery tomorrow. Rationale: An elective surgical procedure can be rescheduled for a later date. The nurse notes a client's postop leg is cool with a cap refill greater than 4 sec and calls the healthcare provider. After 30 min of not receiving a return call from the provider, which action should the nurse take first? A. Attempt to recall the same provider. B. Notify the hospital's "on call" nursing supervisor. C. Continue to monitor and call if there is a change. D. Describe the problem to the answering service. A. Attempt to recall the same provider. Rationale: The provider may have inadvertently not received the first call, so A is best first. According to TeamSTEPPS, 2 attempts should be made to notify the provider before proceeding through the chain of command. The nurse witnesses a male client's signature for surgical consent for a Billroth II procedure after the surgeon discusses the procedure and its implication with the client. After signing the consent, the client questions the importance of a change in his diet postop. What action should the nurse implement? A. Review information about dumping syndrome. B. Have the client sign another consent. C. Notify the surgeon about the client's comment. D. Explain the surgical procedure. A. Review information about dumping syndrome. Rationale: Further review of info about potential dumping syndrome which is managed postop with dietary modification after a Billroth II (partial gastrectomy), should be explained to address the concern. The nurse educator is teaching the nursing staff about a new computerized documentation system that is recently implemented. What information is the best indication that the education is effective? A. A decrease in number of calls to the technology department. B. Less time for nursing staff to complete the daily charting. C. An increase in staff acceptance of computerized charting. D. An improvement from pretest scored on the training session. B. Less time for nursing staff to complete the daily charting. Rationale: Being able to use the system to accomplish charting more efficiently and in less time compared to previous documentation techniques indicates the staff has learned how to use the system effectively. When planning care for a client with polycystic kidney disease, which collaborative problem has the highest priority? A. Hypertension. B. Calculi formation. C. Acute renal failure. D. Infection A. Hypertension. Rationale: BP control has the highest priority, which is necessary to reducce cardiovascular complications and slow the progression of renal dysfunction, which can contribute to B, C, and D.