NURSING101 HESI MANAGEMENT B,GRADED A.

1. 1.ID: A single-parent mother brings her 3-year-old daughter to the emergency department after the child fell off a playground swing at school and hit her head. Which finding should prompt the nurse to advocate for continued hospital observation of the child instead of discharging the child to care at home? o The mother states they do not have the money to pay for transportation home. o The child had a 10 second loss of consciousness immediately after the fall. o The mother is slurring her words and is not attentive to discharge instructions. Correct o The child indicates that she is tired and wants to take a nap. Having a responsible adult to make on-going observations is the most important criteria for discharging anyone to their home after a head injury. The child (who needs observation) should not go home with an impaired adult (C). Alternative arrangements can be made regarding the follow-up care (A). The events of the head injury do not necessarily indicate the need for hospitalized observation (B). It is normal to be drowsy after a concussion (D); immediate intervention is needed if the child cannot be aroused from sleep. Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: A hospital received a bomb threat. While the fire department personnel are evacuating the clients, what action should the charge nurse perform? o Obtain a current roster of clients assigned to the unit. Correct o Ensure that the narcotics are secured and locked up. o Move clients' medical records to a safe location. o Notify the operator when the unit is evacuated. Obtaining a current roster of clients assigned to the unit (A) will help the fire department ensure that all clients are evacuated. In this possibly life-threatening situation, evacuation of personnel and clients is a high priority action, while (B and C) are low priority tasks. The hospital operator should also be evacuated (D). Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: The nurse-manager observes that a staff nurse consistently fails to complete assigned care for clients who are obese. When counseling this employee, what issue is the priority concern? o Violation of ethical principles. Correct o Poor time management skills. o Dissatisfaction of co-workers. o Reduction of client complaints. The priority concern is the lack of fair and equal treatment of obese clients assigned to this staff nurse for care. This reflects a violation of the ethical principle of justice (A). Counseling the nurse about (B) is important because using time effectively allows the nurse to ensure that all clients receive fair and equal treatment, but this is of less concern than (A). (C and D) may also be important concerns, but they are secondary to ensuring justice. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: The home health nurse is planning care for a client with diabetes. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)? o Notify the healthcare provider of a blood glucose > 400. o Explain the procedure for inspecting the feet daily. o Clean the kitchen and bathroom before leaving. o Assist with bathing and other activities of daily living. Correct Assisting the client with activities of daily living is within the scope of practice for a UAP (D). (A and B) are tasks which should be completed by an RN; UAPs may not take verbal prescriptions from healthcare providers, so the nurse, not the UAP, should inform the healthcare provider about the elevated blood glucose level in case treatment is prescribed. Housekeeping duties are not tasks that the nurse needs to delegate to a UAP employed by home health care agencies (C). Awarded 1.0 points out of 1.0 possible points. 5.ID: A nurse who is caring for a group of clients in the medical department has one unlicensed assistive personnel (UAP) assigned to the same group of clients. Which task should the nurse assign to the UAP? o Accompany a discharged client with chronic renal failure to a private car. Correct o Pick up clients' lunch trays and take them to the dietary department. Incorrect o Obtain a STAT serum glucose level for a client who has a low glucometer reading. o Change the bed linens for a client who is being transferred to the rehabilitation unit. Hospitals require clients to be escorted by hospital personnel to the client's car. This nursing task could be delegated to the UAP (A). The dietary department is responsible for (B). (C) is not within the scope of practice for a UAP. (D) does not need implementation, as the client is being transferred. Awarded 0.0 points out of 1.0 possible points. 5. 6.ID: The labor and delivery nurse calls the healthcare provider to report the onset of late decelerations of the fetal heart rate in a laboring client. The healthcare provider tells the nurse to continue monitoring the client and to call back in one hour. What initial action should the nurse take? o Continue to monitor the client per the provider's instructions. o Report the provider's response to the chief of the medical staff. o Ask the client's husband to call the healthcare provider. o Call the nursing supervisor to report the current situation. Correct Because the onset of late decelerations requires immediate intervention and the presence of the healthcare provider, the nurse should follow the chain of command and immediately notify the nursing supervisor (D). (A) alone will put the fetus at risk. The chief of the medical staff may be notified later (B) by the nursing supervisor, but that will not resolve the present unsafe condition regarding this client and her fetus. (C) inappropriately delegates responsibility for communication with the provider to the client's husband. Awarded 1.0 points out of 1.0 possible points. 6. 7.ID: Which statement best describes managed care that is implemented by a specific healthcare delivery agency? o Each member of the healthcare team performs specific tasks for client care to ensure implementation of a client's critical pathway. Correct o One nurse is responsible for the total nursing process required to meet the client's needs throughout hospitalization. o The nurse collaborates with other healthcare disciplines to plan and implement coordinated client care. o The healthcare provider provides direction for the nurse to assess, plan, and coordinate the client's care. Managed care refers to a system in health care delivery that structures the use, cost, quality, and effectiveness of health services and includes pre-authorization, diagnostic related groups (DRGs), critical paths (A), case management care plans, and variance analysis. Primary nursing is a nursing care model that ensures autonomy, authority, and accountability in providing the total nursing process for the client during a period of hospitalization (B). Case management (C) is under the umbrella of managed care as a cost-containment strategy and a nursing care delivery model that coordinates standardized patterns of care and length of hospitalization. Managed care relies on the healthcare provider (D) as the gatekeeper to minimize unnecessary utilization. Awarded 1.0 points out of 1.0 possible points. 7. 8.ID: A nurse who is working the 11 p.m. to 7 a.m. shift enters a client's room when the pulse oximeter alarms and reads 82%. The client appears to be sleeping. Which action should the nurse take first? o Gently apply oxygen without waking the client. o Record the reading and monitor for further decrease. o Reposition the pulse oximeter until it stops alarming. o Rouse the client and obtain vital signs. Correct It is most important for the nurse to assess the client's respiratory status (D), even if the client must be awakened to do so. (A) is not safe. (B) constitutes unsafe practice because the nurse has essentially ignored the data provided by the pulse oximeter. Repositioning the pulse oximeter might be indicated if the vital sign findings are within normal limits and the client is not exhibiting signs of respiratory distress, but more data needs to be obtained prior to implementing (C). Awarded 1.0 points out of 1.0 possible points. 8. 9.ID: On the second postoperative day, a client is pulseless, apneic, and unresponsive. In what order should the nurse implement these nursing actions? (Arrange from first on top to last on the bottom.) Correct 1. Call for assistance. 2. Initiate chest compressions. 3. Ventilate the client. 4. Delegate emergency responsibilities. Based on the recommendations of the American Heart Association, high quality chest compressions should be the first action in cardiopulmonary resuscitation (CPR). The sequence is compressions, airway, and breathing (CAB). Delegating emergency responsibilities is last. Awarded 1.0 points out of 1.0 possible points. 10.ID: The primary nurse receives the 0700 shift report for 4 clients on a medical unit. When prioritizing care, which action should the nurse implement first? o Administer insulin per sliding scale to a client with a capillary glucose of 285. Correct o Assess the lung sounds of a client with pneumonia who is ready to go home. o Flush the lumen of a client's triple lumen central venous catheter with saline. o Review the potassium levels of a client who receives a daily loop diuretic. The nurse should first administer the insulin per scaling scale (A) to the client with hyperglycemia to prevent further elevation of the serum glucose levels. (B and C) are of less immediacy and can be delayed until the higher priority interventions are completed. The client's potassium level should be checked before administering a loop diuretic (D), but this can be done after administering the sliding scale insulin. Awarded 1.0 points out of 1.0 possible points. 11.ID: The nurse is planning a diabetes education course for a group of clients newly diagnosed with diabetes mellitus. Which collaborative approach is the best use of interdisciplinary team members? o Schedule the pharmacist to teach about treatment of hypoglycemia. o Assign the occupational therapist to teach insulin injection techniques. o Invite the dietician to discuss the timing of meals and snacks. Correct o Ask the physical therapist to discuss scheduling physical activity. The dietician (C) can provide the best expertise regarding diet and mealtime planning for clients with diabetes mellitus. The pharmacist's (A) expertise focuses on medications, not the client's management of hypoglycemia, which includes both food intake and medication actions. The occupational therapist (OT) (B) is skilled in implementing interventions to help the client improve small manipulative skills, but the OT does not have the expertise related to medication administration, which is a nursing responsibility. The physical therapist's (D) expertise involves a treatment plan in therapeutic exercises, but may not focus on the scheduling of activity with diet and medication actions, such as peak, and duration. Awarded 1.0 points out of 1.0 possible points. 12.ID: The charge nurse is assessing clients who are currently in labor. It is most important for the pediatric healthcare provider to be present for which delivery? o 40-week primigravida with hypertension who is receiving magnesium sulfate 2 grams/hour. Correct o 37-week multipara who is receiving penicillin G 2.5 million units IV for Group B Streptococcus. o 41-week multipara who is requesting an epidural instead of a local anesthetic for delivery. o 39-week primigravida with a positive urine drug screen who is receiving antiretroviral therapy. The charge nurse should request that a pediatric healthcare provider attend the delivery of the client who is receiving magnesium sulfate for hypertension (A) because magnesium sulfate crosses the placental barrier and causes CNS depression in the infant. The healthcare provider should be notified of the impending delivery for (B, C, and D), but the pediatric healthcare provider does not necessarily need to attend these deliveries. 13.ID: An older female client signed a living will document two years ago that requested no heroic measures be taken on her behalf. Today she is admitted 6 hours after the onset of left hemiplegia, left-sided neglect, and hemianopsia. When the neurologist asks the client if she wants to be ventilated, she responds, "If it will help." The daughter asks the nurse what the family should do because the ventilator places her frail mother at risk for other complications and is contrary to her mother's original request, which was executed when she was healthy. What information is best for the nurse to provide? o The client's original request based on the signed living will for no heroic measures should be followed. o The family should be guided to support the client's current decision about the ventilator. Correct o The client's cognitive ability should be evaluated before the use of a ventilator is needed. o The family should be directed to discuss alternative treatment options with the healthcare provider. The client's verbalization to accept the ventilator or other treatment should be honored because it is sufficient validation to revoke the client's living will. (A) is invalid if the client decides to revoke the signed living will. (C) is a decision that should be made based on a discussion with the healthcare provider concerning alternate plans for care. Although (D) may help the family understand the risks and benefits of treatment options, the client's right to change her mind is the priority consideration. 14.ID: A nurse sitting in the hospital cafeteria sees a man place a small box in the corner and then look around as though he is trying to determine if anyone is looking at him. He then walks quickly to the cafeteria exit. Which action should the nurse implement first? o Make a mental note of the appearance of the man. o Alert the kitchen staff and have them call 911. o Use the nearest phone to notify hospital security. Correct o Calmly instruct everyone in the cafeteria to leave. All hospital staff should be alert for suspicious behavior. When such a situation is reported, the hospital security (C) handles it by implementing (A, B, and/or D). Such actions are based on the policies and procedures the security department is trained to follow in this type of situation. Awarded 1.0 points out of 1.0 possible points. 15.ID: A nurse receives an emphatic complaint from a client in a semi-private room that the night shift nurse did not come into the room the entire night. What action should the nurse implement first? o Telephone the night shift nurse as soon as possible to ask about the situation. o Review the night shift nurse's documentation with the charge nurse. Correct o Discuss the situation with staff to determine if this client has a history of complaining. o Verify occurrence with client's roommate while he's ambulating in the hall. The client's concern needs to be assessed immediately. This can best be accomplished by reviewing the documentation with administration, i.e., the charge nurse, to determine the client's needs and the night nurse's response. The night shift nurse may need to be contacted at some point (A) but reviewing the documentation should occur first. The nurse should not discuss the situation with (C or D). Awarded 1.0 points out of 1.0 possible points. 16.ID: What is the most effective time management strategy for a nurse who needs to review 10 client records in 2 weeks? o Designate 15 minutes a day to respond to each time-waster. o Delegate other nursing responsibilities to the team members. o Schedule specific times on a written calendar to review 2 charts per day. Correct o Review all records 2 days before the due date to focus on the deadline. Creating a disciplined approach by scheduling time periods for each issue is the most effective time-management strategy (C). Although (A and B) are options, the priority responsibility is to accomplish the goal within the designated time frame without imposing on others. (D) can create more stress that may hinder accomplishing the goal. Awarded 1.0 points out of 1.0 possible points. 17.ID: Which task should the nurse delegate to an unlicensed assistive personnel (UAP)? o Update the nutrition needs in the plan of care. o Bathe an unconscious client with decubitus ulcers. Correct o Teach insulin self-administration for a client with Type 1 diabetes. o Evaluate goal attainment for a client with a below-the-knee prosthesis. Delegation requires determining which staff member is capable of performing what tasks. Basic hygiene (B) is within the role of the UAP. Coordination and planning of care (A), teaching (C), and evaluating desired goal attainment or client outcomes (D) are responsibilities outside the scope of practice for the UAP, and within that of the nurse. Awarded 1.0 points out of 1.0 possible points. 18.ID: Based on the scope of practice of the practical nurse (PN), which task should the nurse assign to the PN? o Transport a client to x-ray. o Restock sterile supplies. o Assist with a lumbar puncture. Correct o Distribute afternoon nutrition supplements. Delegation should include the right task, the right skill, and knowledge about the responsibilities of the PN or UAP. The PN's scope of practice includes (C). (A, B, and D) can be delegated to UAPs. Awarded 1.0 points out of 1.0 possible points. 19.ID: The nurse-manager wants to assign an agency nurse to a client who has a new tracheostomy. What action should the nurse-manager implement? o Assign the nurse to the client with the tracheostomy and evaluate the care given. o Ask the nurse about her competency to care for the client with the tracheostomy. Correct o Request the agency to send a nurse who is experienced with tracheostomy care. o Transfer the client to another nurse and use the agency nurse for basic hygiene tasks. The nurse-manager should verify the competency of the agency nurse by soliciting information about the specific skill before the beginning of a shift or assignment (B). (A) does not ensure safe care. (C) is not time efficient. (D) is not effective use of the nurse's scope of practice. Awarded 1.0 points out of 1.0 possible points. 20.ID: A nurse is complaining about the way medications are being administered on the nursing unit. What action should this nurse implement? o Discuss concerns with other nurses on the unit. o Continue with the present unit policy and procedures. o Propose an alternative method to administer the medications. Correct o Relay the perceived problem to the director of nursing services. To facilitate change, an alternative method should be suggested (C) to managerial nursing staff. Although (A) is often a component of generating ideas, it does not lend itself to implementing the change process. (B) may propagate resentment and increase the risk for medication errors. (D) does not follow the chain of authority. Awarded 1.0 points out of 1.0 possible points. 21.ID: To implement change in the work environment, which action is most important for the nurse-manager to take? o Solicit input from coworkers at the beginning of the process. Correct o Present to coworkers the advantages of using a different plan. o Examine similar change processes in other institutions. o Evaluate the feasibility of implementing the proposed change. The most important component for successful change is soliciting input from coworkers (A) which gives all team members ownership in the change. Although a successful change process involves cognitive exposure to the change idea (B) and working to generate alternative solutions (C and D), (A) best ensures cooperation and success of the change. Awarded 1.0 points out of 1.0 possible points. 22.ID: Which task should the nurse delegate to the an experienced unlicensed assistive personnel (UAP)? o Evaluate the ability of a client to swallow ice one hour after a gastroscopy. o Assist a client with initial ambulation after a hip replacement using a walker. Incorrect o Obtain a sterile urine specimen from an indwelling catheter with a closed drainage system. Correct o Change the disposable tracheostomy inner cannula when secretions become tenacious. Functions of assessment, evaluation, and nursing judgment are performed by the registered nurse (RN). Collection of sterile urine specimens (C) falls within the role of the UAP. (A and B) require assessment and evaluation. (D) requires the technical skills and knowledge of the RN. Awarded 0.0 points out of 1.0 possible points. 23.ID: A new graduate nurse places a folder on the food cart so intake can easily be recorded, but at the hospital where the nurse is employed, intakes are often estimated because no recordings are made as the trays are picked up. At a staff meeting, the nurse suggests that the recordings be made as trays are picked up. What factor related to entry into practice is the nurse-manager using when the suggestion moves to the implementation of a policy? o Nurturing. o Mentoring. o Biculturalism. Correct o Role modeling. Biculturalism (C) is the merging of learned ideals with the values of the workplace. Role modeling (D) involves observing experienced nurses, often in leadership positions, to internalize desired qualities during role transition. Nurturing (A) means encouraging and supporting nurses as they learn and grow. Mentoring (B) is a mutual interactive method of learning in which a knowledgeable nurse inspires and encourages a novice nurse. Awarded 1.0 points out of 1.0 possible points. 24.ID: The practical nurse (PN) is working with the registered nurse (RN) to provide care for several clients. Which task should the RN, rather than the PN, perform? o Apply a neck brace prior to ambulating a client the first day after a cervical laminectomy. o Assist a healthcare provider performing a joint fluid aspiration of a client's knee. o Irrigate and pack the stage IV coccygeal pressure ulcer for a client with paraplegia. Correct o Remove the staples from a client's incision one week after hip arthroplasty. Care of a stage IV pressure ulcer (C) is a complex, sterile procedure that requires assessment of the wound, and evaluation of the effectiveness of the treatment plan, and should be performed by the RN. (A, B, and D) are procedures that require the skill and expertise of a licensed nurse, but are within the scope of practice for a PN (C). Awarded 1.0 points out of 1.0 possible points. 25.ID: A Spanish-speaking client is scheduled for surgery in the morning and preoperative teaching needs to be completed. Since the primary care nurse speaks very little Spanish, which person is best to translate the instructions to the client? o A Spanish-speaking UAP who has worked on the unit for many years. o The client's husband who is an attorney at a large local law firm. o A practical nurse working on another unit who speaks fluent Spanish. Correct o The primary care nurse with the help of the Spanish speaking UAP. A Spanish-speaking nurse (C) has the most knowledge about preoperative teaching and has the best command of the language, so this is the best person to provide translation services. Despite long-term employment on the unit, the UAP (A) does not have the same knowledge base as a practical nurse. The husband (B) is personally involved and does not have knowledge about preoperative care. Spanish-speaking expertise is necessary to accurately implement preoperative teaching, and the UAP's assistance does not provide adequate language expertise (D). Awarded 1.0 points out of 1.0 possible points. 26.ID: Four clients arrive on the mental health unit for admission at the same time. Which client should the nurse assess first? o An older adult with Alzheimer's disease who is confused. o A young adult with phobias that interfere with daily activities. o An adult with schizophrenia who stopped taking medications. o A middle-aged adult with acute mania who is pacing the hallway. Correct The nurse should first assess the client with symptoms of mania and hyperactivity (D) because if the client's judgment is extremely poor, there is a potential for risk of injury to self and others, and the client may need constant observation. The clients in (A, B and C) can be monitored by another staff member until the nurse can complete the assignments. Awarded 1.0 points out of 1.0 possible points. 27.ID: A client is brought to the hospital in cardiac arrest by emergency personnel who are performing resuscitation. The spouse arrives as the client is taken into a treatment room and asks to stay with the client. What action should the nurse implement? o Insist that the spouse wait outside the room while resuscitation is being performed. o Allow the spouse to be present and ensure that a member of the team explains the care given and answers questions. Correct o Explain to the spouse that there will be no time for explanations during the resuscitation efforts. o Advise the spouse that if unsuccessful, the resuscitation scene should not be the last memory of a loved one. Research supports the positive benefits of family presence during invasive procedures and cardiopulmonary resuscitation to clients, family, and staff. Facilitating family presence allows family to view themselves of active participants and completes the last step of the secondary survey in the care of an emergency client (B). (A) does not facilitate family presence. Someone should be assigned to the family to explain the care being delivered and to answer questions, not (C). (D) does not offer the spouse support and is not recommended. Awarded 1.0 points out of 1.0 possible points. 28.ID: The director of nursing of a long term care facility is developing a quality improvement project for the facility's units and establishes that a goal of the project should be consistent documentation of pain for all residents. Which statement is the best indicator of this goal's achievement? o All of the nursing staff attend mandatory inservice sessions. o After one month, an audit shows a 20% improvement in documentation. Correct o Random selection of a nurse's charts shows thorough documentation. o The staff agree that documentation has improved by 80%. The best indicator that learning has taken place is evidence of change in behavior, which is indicated by a 20% improvement as evidenced with a chart audit after one month (B). Attending mandatory inservice (A) does not necessarily mean learning takes place or that there is an ability to apply the new information. While one nurse is achieving the desired goal (C), it does not indicate the project is achieving overall staff improvement in documentation. Opinions lack objectivity and are not a qualitative evaluation (D). Awarded 1.0 points out of 1.0 possible points. 29.ID: The nurse is caring for a client with rhabdomyolysis after sustaining multiple crushing injuries. Which intervention should the nurse include in the plan of care to prevent acute renal failure? o Central venous catheter insertion for hydration. Correct o Blood specimen collection for electrolyte analysis. o Antiinflammatory and opioid analgesics for pain. o Diuretic IV administration for third-spacing fluids. Crushing injuries release myoglobin (rhabdomyolysis) into the circulation, which can occlude distal renal tubules and cause acute tubular necrosis (ATN) or renal failure. To prevent renal complications, the nurse should prepare the client for the administration of copious IV fluids after CVC insertion (A) to enhance urinary secretion of myoglobin and iron by-products. Although crushed cells release potassium and cause inflammatory reaction, third spacing fluid loss, acidosis, and shock, (B, C, and D) do not minimize the risk of renal complications. Awarded 1.0 points out of 1.0 possible points.