The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. - Assisting a client to ambulate using a gait belt. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. 3. What was the hint? It is quicker to administer medications intravenously in the hospital Education Which response by the LPN is appropriate in response to the inappropriate delegation? d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. 4. Placing a washcloth in the bathroom sink prior to cleaning. Review a low-sodium diet for a client who has hypertension. Which of the following methods should the nurse plan to use? c. Hallucinations at the onset of sleep Serve food that have a hot/cold balance The client attempted to climb over the side rails and fell Incorrect: This group of clients needs specific teaching. Administer sodium polystyrene sulfonate enema. c. I suggest you talk with a mental health counselor about your concerns Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. Most of the following sentences contain errors in the use of modifiers and comparisons. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. 5. 3. e. Suctioning a client's new tracheostomy tube, 93. b. American Sickle Cell Anemia Association c. Why are you crying? The client states, "I am so nervous about what the doctor might find during the test." Select all that apply. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. (SATA) -Bathing a client who had an amputation 2 days ago. a. c. Inform the surgical team to cancel the client's surgery a. A nurse is preparing to move a client who is only partially able to assist up in a bed. Ask the charge nurse to evaluate the intervention. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. The third client would be the one needing a dressing change. The nurse is using which level of communication at this time? This task cannot be delegated to the LPN/LVN. a. The client is getting better. Read all the current literature related to oral care on unresponsive clients. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. Tenderness over the symphysis pubis Which of the following statements should the nurse make? Yes! 3. Anyone over age 18 can have an Advanced directive. 1. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. c. I should purchase a carbon monoxide detector for my home This referral would be appropriate. Provide an adaptive feeding device for the client The client with cystitis is stable and has a predictable outcome. a. I will keep my walker at the end of my bed Administering IV pain medication to a two day post op client. 1. b. Urinary frequency for several days A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. 3. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. For which of the following tasks should the nurse wear protective eye equipment. Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. b. To confirm the placement of the NG tube 1. Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. c. Decreased sodium excretion A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. 2. 5. Following the teaching, the nurse asks the client to describe one physical effect. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. 1. Complete blockage of the large intestine. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. b. 1. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? a. a. Auscultate breath should at least ever 2 hr A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 1. d. Determine if the client uses hearing aids, b. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. d. I will place a bath seat in my shower to use when I bathe, b. a. Client eating a simple-carb snack due to weakness. 3. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? 4. a. Comatose client with end stage chronic obstructive pulmonary disease. The nurse should call for immediate help so that a safe care environment is maintained for all clients. The nurse who made the medication error should take which of the following actions first? Incorrect: Atrial fibrillation places the client at risk for blood clots. 2. 1. 2. b. Assigning tasks to an AP Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? A charge nurse is making assignments for an oncoming shift. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? A nurse is creating a discharge plan. d. Move to the opposite side of the pack and open the fourth flap, 54. d. Sleep apnea 4., & 5. 1. c. Changing a dressing, 78. A client with an above the knee amputation reporting phantom pain. 4. 4. 2. 2. 3. b. Correct: This group of clients is primarily med surgical. the nurse responds, "don't worry, no one will harm your family." Both of these clients are terminal. Which of the following statements should the nurse identify as an indication that the client requires further clarification? 2. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Which of the following actions should the nurse include in the plan? 1. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. If the client is unstable, the nurse would retain the role of measuring the vital signs. Client prescribed antibiotics for cystitis. What task would be best to assign to the LPN/LVN? a charge nurse is making client care assignments for the day. 2. b. 3. Observe the client before taking further actions 4. Allow the UAP to work without supervision. 6. b. c. There is fluid leaking around the insertion site Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. The RN with 8 years' experience in the Intensive Care Unit. b. I'll use the cleansing wipes from the front to back 1. b. Notify the charge nurse of the observations. 1. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Notify the board of nursing (BON) that the float nurse is an alcoholic. Client who is a diabetic experiencing diabetic neuropathy. d. Identifying the client by name when making a referral for home health services, 30. a. Administer tap water enemas until clear at 6 AM. 3. Include any relevant statements the client made about the ulcer Incorrect. Reach around the pack and open the top flap away from the body, 53. c. Initiate a liquid diet for the client The nurse cannot allow the UAP to perform advanced tasks. Nursing questions and answers. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. The client reports constipation for 4 days which may be an indication of worse problems. A lack of rapid eye movement (REM) sleep 1. Electric cords behind the furnitrure Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. a. Assist a client to ambulate using a gait belt. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. 4. The nurse suggest that the family might need to respite care services. What is the major histological difference between thick and thin skin? Collecting I & O totals for unit clients at the end of shift. 2. This could cause a medical emergency. Client scheduled for breast reconstruction after mastectomy. A nurse is implementing direct nursing care for a group of clients in an acute care facility. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Incorrect: The RN is responsible for collecting data. Furosemide 40 mg PO q.d. This is an appropriate and safe action for the unlicensed nursing assistant to do. Which action by an unlicensed nursing assistant would require the nurse to intervene? The nurse is reviewing some clients' prescriptions. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. The area surrounding the insertion site feels warm to the touch Elevating the head of the bed 30- 40 for the client post thoracotomy Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Which client should the nurse assess first? Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. 3. A nurse asks a client how he is feeling. Incorrect: The nurse cannot assign teaching to the UAP. Symbolic communication 4. Use double bagging to remove soiled linen from the client's room Soaking the dentures in hot water a. They have found my address and are coming for my family!" Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. a. A high concentration of carbon monoxide can cause death This would be out of the UAP's scope of practice. Client reporting epigastric pain and nausea after eating. b. Which of the following infection-control precautions should the nurse use caring for this client? 3. Incorrect: The RN is responsible for teaching. This client should report an improved respiratory, not shortness of breath. Which of the following statements should the nurse identify as an indication that the client understands the instructions? In which situation should the nurse consult the client's advanced directive? Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. b. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). 6. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. c. Inflate the balloon when the urine flow stops Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. A nurse receives a client care assignment from the charge nurse that he believes is unfair. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. 1. Feedback 3. A nurse is caring for a client who has a mental health disorder. Client with ureterolithiasis who requires frequent PRN pain medication. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. A charge nurse is making client care assignments. It's unfortunate that I have to be in the hospital for this treatment The nurse could definitely be part of the committee. 1. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. 1. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 A nurse is caring for a client who has a hip fracture that requires surgical repair. a. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. 2. Reach around the pack and open the top flap away from the body The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. b. Select all that apply What action should the nurse take after mistakenly administering the wrong medication? The nurse should not lecture, scold or argue with the float nurse. a. 5. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. Which of the following responses should the nurse make? c. Check to see if the suction equipment is working Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. 2. In option #4, we see that the leading zero is missing from the prescription. d. Perception Prior to shift report, the charge nurse is making assignments for the nurses on the shift. b. d. Complete an incident report, 70. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. a. There may be a good reason that the tray was not served. e. Feed a client who had a stroke 3 months ago, 32. 1. Which of the following info should the nurse include? This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. a. 1. Drag and Drop the items from one box to the other. 1. A goal for this client is to use proper body mechanics at all times. What is the most appropriate action by the charge nurse? There are a total of 10 adult clients. Elderly client who fell and fractured the left femoral neck. Select all that apply The below statement corresponds to a numbered sentence in the passage. d. I shouldn't advice you about what is ultimately a personal decision, b. Now, in Option #2, we see a dangerous prescription. Battery Incorrect: The charge nurse does not have to assess every client. 1., 3, & 4. b. A client with diabetes admitted for debridement of a foot ulcer. When determining if the client is eating a well-balanced diet Which of the following actions should the nurse take to assist the client with feeding? c. Physical therapist c. Review the client's progress toward personal objectives Besides yourself, there are the following staff: Your unit has 12 beds. 1., 2., 4., & 5. a. 5. A nurse is filling out an incident report after finding a client lying on the floor. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. A nurse caring for a client is using active listening skills. a. I will keep spare crutch tips handy 2. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. b. b. What action should the nurse implement first to ensure client safety? Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. A client post pacemaker insertion, awaiting discharge instructions. This protein is released by cells in the stomach. c. Discard the tablet and obtain another dose of medication -Review a low-sodium diet for a client who has HTN c. Assist the client to the floor and begin mouth-to-mouth A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Which of the following actions should the nurse take first? d. Let's wait until tonight to see if he continues his behavior, 63. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? b. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. The area surrounding the insertion site feels warm to the touch, 61. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. 3. b. I will keep the fluorescent ceiling light on in my room at night 3. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. The LPN can monitor the wound and provide care to the PEG insertion site. In which harmonic number n is the string vibrating? Select all that apply Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Which nurse should be assigned to care for this client? a. A nurse receives a client care assignment from the charge nurse that he believes is unfair. 1. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Teach the UAP to change surgical dressings. C. Review a low-sodium diet for a client who has hypertension. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. However, providing care for missing teeth would also be within the LPN scope of practice. 2. The client is apparently stable and does not require any advanced assessment skills or specialized care. B. The situation should be explored before bringing the supervisor in on the situation. 1. Removing the client's dentures Risperidone .5 mg PO daily Call the family of a client suffering from dementia to discuss long term care placement. Decreased or suppressed respiration are priority. Feedback Places the soiled linen in the floor before bagging it Select all that apply 2. Which of the following findings indicates that the client is meeting this goal? Correct: The UAP can remind the client to do something that has already been taught by the nurse. Lumbar puncture reporting a headache. Which of the following actions should the nurse take? c. I'll bear weight on my ankle for 10 minutes every hour The nurse has received the change-of-shift report.
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