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Management of Surgical Unit The nurse manager is the charge nurse on a busy surgical unit in a major metropolitan hospital. The charge nurse is working with a team composed of registered nurses (RNs), practical nurses (PNs), and unlicensed assistive personnel (UAPs). The charge nurse for the previous night shift is giving verbal report to Ms. Hatch and the oncoming staff nurses. During the report, one of the UAPs interrupts to state that a client is vomiting. How should Ms. Hatch respond...

Management of a Pediatric Unit Which phone message requires the most immediate response by Ms. Sanku? A school social worker who is reporting that a local teenager who often hangs out around the clinic has made death threats and expressed thoughts of suicide. Which situation requires the most immediate follow-up by the nurse? A mother expressing concern that her baby refuses to take formula, stating that the infant's "soft spot" seems more sunken. Which child requires the most immedi...

LPN HESI MATERNAL Which physiological cause(s) for constipation during pregnancy should the practical nurse (PN) explain to a client in the first trimester? (Select all that apply.) 1. Displacement of the colon. 2. Tightening of the anal sphincter. 3. Change in nutrient absorption. 4. Shifting of liver placement. 5. Decrease in peristalsis. 6. Increase bile production. 1. Displacement of the colon. 5. Decrease in peristalsis. During pregnancy, the enlarging uterus compresses and disp...

Section 1 Nursing Process: Assessment The nurse admits Raymond to a private room at the end of the hall. According to hospital protocol, the nurse puts on a mask before starting the admission process. Raymond tells the nurse that his significant other is downstairs and that he would like for him to stay in the room with him. How should the nurse respond? "Your healthcare provider (HCP) wants you to get some rest." Raymond is requesting an opportunity for psychosocial support, which sh...

HESI STROKE Which statement about transient ischemic at- tack (TM) is accurate? a. TIAs do not cause permanent brain damage. b. TIA increases the risk of stroke. c. Symptoms of a TIA usually resolve in 10- 15 minutes. d. After a TIA, a patient is prescribed a beta blocker. B The nurse is preparing to discharge a patient with transient ischemic attacks. What treatment areas does the nurse include in discharge teaching? (Select all that apply.) a. Reduction of high blood pressure b. Dru...

HESI RN Medical Surgical EXAM The nurse is assessing a clients laboratory values following the administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome? A. Hemoglobin of 10 g/dl B. Serum calcium of 5mg/dl C. Serum PTT of 10 seconds D. Oxygen saturation of 90% Answer: B TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 is low and so is an indicator of possibl...

HESI RN MEDICAL SURGICAL EXAM Questions Answers & Rationales The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's b...

HESI RN Med Surg II A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client: Hangs the irrigation bag on the door clothes hook during fluid insertion Following surgery, a client asks the nurse if he or she can help measure intake and output. What is the best nursing response? Assess the client's ability to measure t...

Fundamental HESI Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. C) Examining a chest x-ray obtained after the tubing was inserted B...

HESI RN Fundamentals B 1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals. C (The nursi...