Leadership Hesi and Management Review 2024

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 surgical unit. Which task is best for the charge nurse to assign to the nurse? The insertion of a foley catheter for a client diagnosed with septicemia 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? Advise the staff nurse to remove the restraints from the client’s wrists 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? Risk management nurse 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? Peripheral pulses present with full range of motion of both legs 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? Monitor urinary output hourly 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? Review the institutional policy for delegation with the nursing supervisor. 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? 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. 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? Meet with the UAP to discuss respectful client care strategies. 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? Distraction 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? The abdomen is rigid, tender to touch, and distended An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider’s office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family? The client is grieving normally in response to her husband's health and hospitalizations is not necessary The charge nurse on a surgical unit is assessing the morning lab work on four clients. Which client’s lab finding should be reported to the healthcare provider immediately? An elderly client in end-stage renal disease who has a creatinine level of 2.4 mg/dL (212 micromol/L) and a BUN of 84 mg/dL (30 mmol/L) The charge nurse needs to determine is an additional nurse should be called to help staff 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 clients on the unit. The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first? Tell the staff to keep all clients and visitors in the client rooms with the doors It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client? An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L SI). The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement? Review the medication transcription with the nurse. The nurse is caring for a group of clients with help of an experienced unlicensed assistive personnel (UAP). Several specimens need to be collected and sent to the lab. Which specimen collection can the nurse delegate to the UAP? Fecal drainage sample Urine from indwelling catheter A client is admitted with exacerbation of chronic obstructive pulmonary disease (COPD) and reports that it is difficult to eat due to shortness of breath (SOB). Which tasks should the nurse to delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) Offer high caloric foods such as milk and ice cream Maintain a clean and pleasant environment during meals Assist the client with eating small frequent high calorie meals Set up the food and drink containers within easy reach After receiving morning report on an acute care unit, which client should the nurse assess first? A client sitting close to the nurse’s station who has been restrained for the past six hours. A nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP) are working as a team to provide care for an acuity ill client required immediate bedside insertion of a chest tube. Which assignment is the best use of each person's skills? The UAP obtains an oxygen saturation level while the RN reports findings to the healthcare provider The nurse assigns an unlicensed assistive personnel (UAP) to apply sequential compression devices to a client. Which instruction should the nurse include when assigning this task to the UAP? Report any change in color in the client’s feet or legs Because of budget cutbacks, a policy was established which mandates that when the census is low, nurses will be sent home. For the third time in two weeks, a nurse who has been employed at the hospital for three months is sent home immediately after arriving for work. The nurse is obviously upset and begins to cry when told to go home. Which action should the charge nurse take? Take the nurse to a private place and listen to the nurse’s description of A client with leukemia is hospitalized for weakness, fatigue, and anemia. The client is restless and tachycardic. Which intervention is most important for the nurse to include in the plan of care? Maintain protective isolation The nurse caring for a client with bacterial meningitis is preparing report for the oncoming nurse. It is most important to include which assessment finding in the report? Increasing pulse pressure The nursing supervisor sends an unlicensed assistive personnel (UAP) to a medical unit to replace an absent UAP. When delegating the task of obtaining client’s blood sugar levels using a glucometer, which action is most important for the nurse to implement? Observe the UAP obtain a fingerstick glucose level using the glucometer A healthcare provider notifies the nurse that new prescriptions have been written for a client. Which is the first action the nurse should implement? Read all of the new prescriptions for the client written by the provider. The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? Monitor for signs of bleeding