Evolve HESI Leadership Management Guaranteed
to Boost Your Grades WITH MULTIPLE QUESTIONS
AND THE CORRECT ANSWERS With Thorough
Explanations and Correct Responses
Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the
control value demonstrates that warfarin has reached a therapeutic level. The long-term
antibiotic course (and follow-up lab work) can continue at home through the PICC line
(Options 1, 2, and 5).
(Option 3) Large intestine peristalsis does not return for up to 3-5 days. The client cannot
be discharged until able to tolerate oral intake with normal elimination. The client has to at
least be passing flatus
(Option 4) Coffee ground emesis indicates upper gastrointestinal bleeding. The etiology
and treatment need to be determined before the client is discharged.
Educational objective: Those who are stable for discharge include the client with multiple
sclerosis with ataxia and diplopia, the client on warfarin (Coumadin) that has reached the
therapeutic effect, and the client with a PICC line for a long-term antibiotic course.
The health care provider gives the preoperative nurse a signed consent form and walks
away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why
do I need surgery?" What is the most appropriate action?
1. Call the nursing supervisor
2. Call the operating room scheduler and cancel the surgery
3. Page the health care provider and request clarification on behalf of the client
4. Report the incident to hospital administration - CORRECT ANSWER- -3
,Informed consent requires that the health care provider performing the procedure explain
everything to the client's satisfaction (within reason). Signed consent may be witnessed by
the nurse. If the client does not fully understand informed consent, the nurse must notify
the health care provider or refer up the chain of nursing command. The nurse is not
responsible for verifying that the client understands the procedure and its respective risks.
(Option 1) This would be appropriate if the health care provider refuses to talk to the client.
(Option 2) This is not the nurse's responsibility; this request would have to be relayed up
the chain of nursing command.
(Option 4) This is premature; the incident is isolated and not all facts are known.
Educational objective: Clients may not consent to an invasive procedure without being
informed of the clinical reasoning, consequences, and possible complications.
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the
documentation of clients' capillary glucose results rather than performing the test. What is
the best action by the charge nurse to handle this situation?
1. Ask a client if the UAP has performed the test
2. Discuss the importance of task completion and accurate documentation in a staff
meeting
3. Give the UAP a verbal warning not to falsify data
4. Take a client's capillary glucose personally and compare it to the recorded result -
CORRECT ANSWER- -4
, The best initial result is to assess and validate the charge nurse's perception. Doing the test
and comparing results randomly/intermittently will give data to prove/disprove this
concern.
(Option 1) It could cause concern to involve a client when there may be an issue about
inadequate provider care. The nurse should handle it independently.
(Option 2) It is good to reinforce policies in general announcements to the entire staff,
especially if wide-spread compliance is a concern. However, there is only one person that
is suspected of not adhering in this case. Speaking out is often a general step taken, but the
intended individuals usually don't hear the information. In addition, this is information that
the staff has known/heard before.
(Option 3) The normal discipline process is a verbal warning, a written warning,
suspension, and termination. To initiate the process, there has to be evidence of wrong
doing. However, it is only a suspicion at this point.
Educational objective: When deliberate inaccurate documentation is suspected, gather
evidence before confronting the staff member. One way of doing this is by checking the
data personally and comparing it to what has been documented.
The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is
completing a bath and placing thigh-high anti-embolism stockings on the client. Which
situation would cause the nurse to intervene?
1. UAP applies the anti-embolism stockings while maintaining the client in supine position
2. UAP carefully smoothes out any wrinkles over the length of the stockings
3. UAP checks that the toe opening of the stockings is located on the plantar side of the
foot
4. UAP rolls down and folds over the excess material at the top of the stockings - CORRECT
ANSWER- -4
to Boost Your Grades WITH MULTIPLE QUESTIONS
AND THE CORRECT ANSWERS With Thorough
Explanations and Correct Responses
Ataxia and diplopia are expected signs/symptoms of multiple sclerosis. Two times the
control value demonstrates that warfarin has reached a therapeutic level. The long-term
antibiotic course (and follow-up lab work) can continue at home through the PICC line
(Options 1, 2, and 5).
(Option 3) Large intestine peristalsis does not return for up to 3-5 days. The client cannot
be discharged until able to tolerate oral intake with normal elimination. The client has to at
least be passing flatus
(Option 4) Coffee ground emesis indicates upper gastrointestinal bleeding. The etiology
and treatment need to be determined before the client is discharged.
Educational objective: Those who are stable for discharge include the client with multiple
sclerosis with ataxia and diplopia, the client on warfarin (Coumadin) that has reached the
therapeutic effect, and the client with a PICC line for a long-term antibiotic course.
The health care provider gives the preoperative nurse a signed consent form and walks
away rapidly. The client turns to the nurse and states, "I don't know what is going on. Why
do I need surgery?" What is the most appropriate action?
1. Call the nursing supervisor
2. Call the operating room scheduler and cancel the surgery
3. Page the health care provider and request clarification on behalf of the client
4. Report the incident to hospital administration - CORRECT ANSWER- -3
,Informed consent requires that the health care provider performing the procedure explain
everything to the client's satisfaction (within reason). Signed consent may be witnessed by
the nurse. If the client does not fully understand informed consent, the nurse must notify
the health care provider or refer up the chain of nursing command. The nurse is not
responsible for verifying that the client understands the procedure and its respective risks.
(Option 1) This would be appropriate if the health care provider refuses to talk to the client.
(Option 2) This is not the nurse's responsibility; this request would have to be relayed up
the chain of nursing command.
(Option 4) This is premature; the incident is isolated and not all facts are known.
Educational objective: Clients may not consent to an invasive procedure without being
informed of the clinical reasoning, consequences, and possible complications.
A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the
documentation of clients' capillary glucose results rather than performing the test. What is
the best action by the charge nurse to handle this situation?
1. Ask a client if the UAP has performed the test
2. Discuss the importance of task completion and accurate documentation in a staff
meeting
3. Give the UAP a verbal warning not to falsify data
4. Take a client's capillary glucose personally and compare it to the recorded result -
CORRECT ANSWER- -4
, The best initial result is to assess and validate the charge nurse's perception. Doing the test
and comparing results randomly/intermittently will give data to prove/disprove this
concern.
(Option 1) It could cause concern to involve a client when there may be an issue about
inadequate provider care. The nurse should handle it independently.
(Option 2) It is good to reinforce policies in general announcements to the entire staff,
especially if wide-spread compliance is a concern. However, there is only one person that
is suspected of not adhering in this case. Speaking out is often a general step taken, but the
intended individuals usually don't hear the information. In addition, this is information that
the staff has known/heard before.
(Option 3) The normal discipline process is a verbal warning, a written warning,
suspension, and termination. To initiate the process, there has to be evidence of wrong
doing. However, it is only a suspicion at this point.
Educational objective: When deliberate inaccurate documentation is suspected, gather
evidence before confronting the staff member. One way of doing this is by checking the
data personally and comparing it to what has been documented.
The nurse enters a client's room just as the unlicensed assistive personnel (UAP) is
completing a bath and placing thigh-high anti-embolism stockings on the client. Which
situation would cause the nurse to intervene?
1. UAP applies the anti-embolism stockings while maintaining the client in supine position
2. UAP carefully smoothes out any wrinkles over the length of the stockings
3. UAP checks that the toe opening of the stockings is located on the plantar side of the
foot
4. UAP rolls down and folds over the excess material at the top of the stockings - CORRECT
ANSWER- -4
