HESI MANAGEMENT OF CARE 2 QUESTIONS AND
ANSWERS
A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy
of needs. Which activities should the nurse perform to meet the client's safety and
security needs? Select all that apply. - Answer -Positioning the bed in a low position
and keeping the side rails up
Monitoring vital signs, such as blood pressure to decrease the risk of falls
Observing a client who has suicidal tendencies to prevent adverse incidents
As per Maslow's hierarchy of needs, to meet the safety and security needs of the client,
the nurse should position the bed in a low position and keep the side rails up to provide
physical safety for the client. Monitoring vital signs, including blood pressure to prevent
risk for falls is an example of a nursing activity that meets the client's safety and security
needs. Observing a client who has suicidal tendencies to prevent adverse incidents is
an example of a nursing activity that meets the client's safety and security needs.
Providing a cold bath to the client to reduce body temperature is an example of a
nursing activity that meets the client's physiological needs. Collaborating with family
members to provide emotional support to the client post-surgery is an example of a
nursing activity that meets the client's love and belonging needs.
The condition of a child dying of leukemia deteriorates, and the child becomes
comatose. The parents state that a relative told them that they should not allow the child
to be resuscitated, but they are unsure. Which response by the nurse best
demonstrates recognition of the ethical issues involved? - Answer -"The final decision
must be made by you and your doctor, but it's important to talk about it."
A client is prescribed apomorphine. Which concern would be a priority while addressing
client needs? - Answer -Operating heavy machinery or driving
Apomorphine is a dopamine agonist, which has side effects of orthostatic hypotension,
drowsiness, and hallucinations. The priority nursing instruction for a client prescribed
apomorphine is to instruct the client to avoid operating heavy machinery or driving.
Entacapone is a monoamine oxidase inhibitor, which causes life-threatening
complications when it interacts with foods containing tyramine. Therefore the clients
who are on entacapone therapy must be advised to avoid foods containing tyramine.
Verapamil is a calcium channel blocker, which may cause bradycardia, so clients who
are on verapamil therapy must be instructed to report fatigue and shortness of breath.
Sumatriptan is a triptan, which may cause cardiac damage. Therefore clients who are
on sumatriptan must be instructed to report chest discomfort and chest pain.
, The registered nurse delegates a task to a new team member for an ongoing process.
Which style implemented by the delegator would be most appropriate in this situation? -
Answer -Selling
How does the nurse leader, being in an executive position, perform Gardner's
motivating task? - Answer -Inspiring the staff and community leaders to achieve desired
levels of health and well-being
The nurse leader can apply Gardner's motivating task by inspiring staff and community
leaders to use clinical services appropriately. Inspiring the staff to achieve the mission
of the organization indicates that the nurse leader is accomplishing the managing
position of Gardner's task. The nurse leader fulfills Gardner's task of envisioning goals
by assisting staff in formulating a vision of enhanced clinical and organizational
performance. The nurse leader executes Gardner's task of explaining by teaching and
interpreting organizational and community-based health information.
The nurse is instructing the student nurse how to administer percutaneous enterostomal
gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student?
Select all that apply. - Answer -Connect tube feeding bag to client and feeding pump.
Flush with warm water before beginning feeding.
Check prescription for correct client formula.
Set correct rate and initiate pump.
Check for diarrhea.
Connect the feeding bag to the client and pump and check for any residual feeding
before initiating the feeding. Always check the most recent tube feeding prescription
before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct
rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should
be assessed. The client's head of bed needs to be elevated at least 30 degrees.
The nurse manager appointed a registered nurse (RN) to provide hospice care for a
client and explained the tasks to be performed. Which tasks has the nurse manager
delegated to the RN? Select all that apply. - Answer -Providing total client care
Teaching the client and family members
Teaching the client about personal hygiene
The registered nurse provides total client care, teaches the family about the client's
care, and teaches the client about personal hygiene. The registered nurse may not
perform all the hygienic tasks and daily activities. These tasks are delegated to the
unlicensed assistive personnel.
ANSWERS
A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy
of needs. Which activities should the nurse perform to meet the client's safety and
security needs? Select all that apply. - Answer -Positioning the bed in a low position
and keeping the side rails up
Monitoring vital signs, such as blood pressure to decrease the risk of falls
Observing a client who has suicidal tendencies to prevent adverse incidents
As per Maslow's hierarchy of needs, to meet the safety and security needs of the client,
the nurse should position the bed in a low position and keep the side rails up to provide
physical safety for the client. Monitoring vital signs, including blood pressure to prevent
risk for falls is an example of a nursing activity that meets the client's safety and security
needs. Observing a client who has suicidal tendencies to prevent adverse incidents is
an example of a nursing activity that meets the client's safety and security needs.
Providing a cold bath to the client to reduce body temperature is an example of a
nursing activity that meets the client's physiological needs. Collaborating with family
members to provide emotional support to the client post-surgery is an example of a
nursing activity that meets the client's love and belonging needs.
The condition of a child dying of leukemia deteriorates, and the child becomes
comatose. The parents state that a relative told them that they should not allow the child
to be resuscitated, but they are unsure. Which response by the nurse best
demonstrates recognition of the ethical issues involved? - Answer -"The final decision
must be made by you and your doctor, but it's important to talk about it."
A client is prescribed apomorphine. Which concern would be a priority while addressing
client needs? - Answer -Operating heavy machinery or driving
Apomorphine is a dopamine agonist, which has side effects of orthostatic hypotension,
drowsiness, and hallucinations. The priority nursing instruction for a client prescribed
apomorphine is to instruct the client to avoid operating heavy machinery or driving.
Entacapone is a monoamine oxidase inhibitor, which causes life-threatening
complications when it interacts with foods containing tyramine. Therefore the clients
who are on entacapone therapy must be advised to avoid foods containing tyramine.
Verapamil is a calcium channel blocker, which may cause bradycardia, so clients who
are on verapamil therapy must be instructed to report fatigue and shortness of breath.
Sumatriptan is a triptan, which may cause cardiac damage. Therefore clients who are
on sumatriptan must be instructed to report chest discomfort and chest pain.
, The registered nurse delegates a task to a new team member for an ongoing process.
Which style implemented by the delegator would be most appropriate in this situation? -
Answer -Selling
How does the nurse leader, being in an executive position, perform Gardner's
motivating task? - Answer -Inspiring the staff and community leaders to achieve desired
levels of health and well-being
The nurse leader can apply Gardner's motivating task by inspiring staff and community
leaders to use clinical services appropriately. Inspiring the staff to achieve the mission
of the organization indicates that the nurse leader is accomplishing the managing
position of Gardner's task. The nurse leader fulfills Gardner's task of envisioning goals
by assisting staff in formulating a vision of enhanced clinical and organizational
performance. The nurse leader executes Gardner's task of explaining by teaching and
interpreting organizational and community-based health information.
The nurse is instructing the student nurse how to administer percutaneous enterostomal
gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student?
Select all that apply. - Answer -Connect tube feeding bag to client and feeding pump.
Flush with warm water before beginning feeding.
Check prescription for correct client formula.
Set correct rate and initiate pump.
Check for diarrhea.
Connect the feeding bag to the client and pump and check for any residual feeding
before initiating the feeding. Always check the most recent tube feeding prescription
before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct
rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should
be assessed. The client's head of bed needs to be elevated at least 30 degrees.
The nurse manager appointed a registered nurse (RN) to provide hospice care for a
client and explained the tasks to be performed. Which tasks has the nurse manager
delegated to the RN? Select all that apply. - Answer -Providing total client care
Teaching the client and family members
Teaching the client about personal hygiene
The registered nurse provides total client care, teaches the family about the client's
care, and teaches the client about personal hygiene. The registered nurse may not
perform all the hygienic tasks and daily activities. These tasks are delegated to the
unlicensed assistive personnel.
