HESI Management | Questions and Answers with complete solution

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 "Do not resuscitate" (DNR) order on file. Which client fits the criteria for a terminal illness? A) 2-year-old child with esophageal burns from drinking drain cleaner who now has a gastrostomy tube. B) 76-year-old female client with Alzheimer's disease who is pacing the halls and trying to "go home." C) 52-year-old male client who had a partial lobectomy and on a ventilator on the 2 postoperative day. D) 43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration. - D) 43-year-old male with amyotrophic lateral sclerosis who is refusing artificial nutrition or hydration. Rationale: "Terminal illness" describes the client's life expectancy as less than six months without life-sustaining measures therefore, a 43-year old male with ALS who is refusing artificial nutrition or hydration describes the client with a terminal disease who may not survive more than a few days after the refusal of food and hydration.The other options do not describe a client with a terminal illness and require further information to clarify the DNR order. When the charge nurse is making assignments, which tasks can be assigned to an unlicensed assistive personnel (UAP)? A) Perform a dressing change, oral suctioning, and admission of a client to the unit. B) Time contractions, determine fetal heart rate, 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 nasogastric tube, collect a stool specimen, and measure intake and output. - C) Take vital signs, give a cleansing enema, and apply soft restraints to an older client. Rationale: After the nurse has validated an individual's competency, the UAP can be assigned tasks such as measuring vital signs, giving a cleansing enema, and applying soft restraints. Tasks that involve assessment should be assigned to licensed personnel--practical nurses (PNs) or registered nurses (RNs). The registered nurse (RN) and unlicensed assistive personnel (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 responsible for medication administration and sterile procedures such as catheter irrigation. The UAP is qualified to provide personal care and measure I&O. The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan? A) Do not allow those with influenza 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 urinary tract infections. - C) Ensure that sterile technique is followed when changing surgical dressings.