Hesi Rn Exit Exam

1. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? RN 2. A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? Teaching a family intermittent (bolus) feedings via G-tube before discharge 3. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? Provide basic hygiene care to all clients on the unit 4. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? Unlicensed assistive personnel (UAP) 5. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? Decrease in chest wall expansion 6. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? A 58 year-old hypertensive with possible angina 7. A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: Determine available community and personal resources 8. The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? The radiation from a mammography is equivalent to 1 hour of sun exposure 9. The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should: ask the client to hold a breath 10. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? Risk for infection 11. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should first: Explore how the planning committee evaluated barriers to the plan 12. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? Report this immediately to the nurse manager 13. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? Administer the medication with a syringe next to the tongue 14. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to: Ask the client for more information about the nature of the bruises 15. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age? Separation anxiety 16. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil 17. Which statement describes the use of a decision grid for decision making? It is both a visual and a quantitative method of decision making 18. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? Drug tolerance 19. The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that: Clumsiness and behavior changes should be reported 20. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Respiratory rate of 32