Nursing Care Scenarios, Exams of Nursing

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HESI Leadership 2024 EXAM NEW

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QUESTIONS WITH VERIFIED ANSWERS

The UAP reports four client situations to the nurse each client is one day postoperative. In which sequence should the nurse assess the clients?(Arrange in order from highest to lowest priority)? The correct order is presented below

• ANSWER 1. An adult who had a splenectomy due to multiple traumas is now vomiting coffee grounds

2. An older adult who had a bowel resection and colostomy has temperature of 99.
3. An older adult who had a laproscopic cholecystectomy reports pain of 6 using 10 point scale
4. An adult who had a liver biopsy is anxious awaiting removal of saline loc for discharge The hospice nurse reviews the plan of care for a client receiving palliative end-of-life home care. The client is cachexic and only able to take sips of water by mouth occasionally. Which instructions should the nurse provide the unlicensed assistive personnel assisting with the client's care? a. Keep the mucous membranes moist. b. Report any change in urine color c. Maintain high Fowler's position. d. Record the client's daily weight.

• ANSWER a. Keep the mucous membranes moist. An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family? a. Managed healthcare plans do not pay for any in-hospital medical evaluations. b. Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital. c. the client is grieving normally in response to her husband's death and hospitalization is not necessary d. Managed care providers have mandatory pre-certification requirements for hospitalization.
• ANSWER c. the client is grieving normally in response to her husband's death and hospitalization is not necessary The nurse is planning care for a client who is experiencing acute pain. Which intervention can be implemented by the unlicensed assistive personnel (UAP) in providing personal care for this client?

a. Distraction b. Biofeedback c. Patient-controlled analgesia d. Guided imagery

• ANSWER a. Distraction A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? a. Maintain strict intake and output. b. Keep the head of the bead raised 45 degrees. c. Assess warmth of extremities. d. Monitor blood glucose levels . - ANSWER a. Maintain strict intake and output. While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? a. Tell the unit clerk to ask the client via the intercom what is needed. b. Ask a coworker to respond to the client whose call bell is alarming. c. Complete the postoperative admission assessment then investigate the call bell alarm d. Investigate the reason for the call bell alarm then complete the admission assessment.
• ANSWER b. Ask a coworker to respond to the client whose call bell is alarming. In reviewing the admission records of a 16 year old male client with acute glomerulonephritis , the nurse notes that the healthcare provider has given no instructions regarding measurement of intake. Which intervention should the nurse take ? a. Ask the client if he knows about the healthcare providers plan to for how much he can have to drink b. Delegate the desk secretary to call the healthcare provider's office and leave a message c. Start and intake and output record and teach the client and family how to record it d. Inform the family that an error was mad but that it was recognized early
• ANSWER c. Start and intake and output record and teach the client and family how to record it The nurse is assigned to care for a client on a medical unit. Based on the notes taken during shift report , which clients situation warrant the nurses immediate attention? a. A teenager who reports continued pain for 30 minutes after receiving oral analgesic b. A young adult with Crihns who reports having diarheaa stools c. An older adult with type 2 Diabetes whose breakfast tray is 30 minutes late d. A ten year old child who is recovering from chemotherapy and infusion pump is beeping

• ANSWER d. A ten year old child who is recovering from chemotherapy and infusion pump is beeping A client has a prescription for 20 units of insophane insulin suspension and regular insulin 70/30 to be administered subcutaneously. The pharmacy has provided a vial of inosphane insulin suspension and a vial of regular insulin. Which action should the nurse implement? a. Draw 10 units of regular insulin , followed by 10 units of insophane insulin suspension into the syringe and administer b. Adminster a combined dose of 20 units of each of the two types of insulin mixed in one syringe c. Consult with healthcare provider about the clients insulin prescription d. Notify the pharmacy that the incorrect insulin has been delivered to the unit - ANSWER d. Notify the pharmacy that the incorrect insulin has been delivered to the unit A postoperative clients respiratory rate decreased from 14 breaths to 6 breaths after administration of ab opioid analgesic. Thirty minutes later , the clients respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administrators a dose of IV naloxone. The charge nurse should counsel the nurse regarding which intervention? a. The decision regarding when to call the healthcare provider b. The documentation of the clients respiratory rate c. The initial administration of the analgesic d. The administration of naloxone via IV
• ANSWER a. The decision regarding when to call the healthcare provider A CNA is preparing to assist a client with influenza and pneumonia with a bath. The nurse observes the CNA wearing a gown and gloves to enter the room. Which action should the nurse take? a. Review the need for the cna to wear a face mask while in close contact with the client b. Assign the cna to provide care for another client and assume full care of the client c. Instruct the cna to notify the nurse of any changes in the clients respiratory status d. Remind the cna to apply fitted respirator mask before entering the clients room - ANSWER a. Review the need for the cna to wear a face mask while in close contact with the client It is most important for the charge nurse to schedule a multidisciplinary to discuss with which client? a. An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dl. b. A woman who is pregnant with twins and whose due date is one week away c. A business exec admitted with Gullian Barre syndrome who has residual bilateral numbness in the lower xtremeties d. A two-year-old who contracted HEP A while at a local daycare center

• ANSWER a. An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dl. The nurse receives a telephone prescription from the healthcare provider for a clients persistent cough and wheezing. The prescription includes a chest xray , an antibiotic , and nebulizer treatment now and PRN. After reading the prescription back to the healthcare provider to ensure accuracy which intervention should the nurse implement first? a. Evaluate breathing b. Start the prescribed antibiotic c. Apply portable oxygen for transport to radiology d. Administer a nebulizer breathing treatment
• ANSWER d. Administer a nebulizer breathing treatment While making rounds the nurse working the night shifts finds a wife of a terminally ill patient lying in the bed with and both are sleeping. Which action should the nurse implement? a. Notify the house supervisor of the situation who will determine what action to take b. Close the door quietly and do not take any further action c. Ask the cna to take the clients vital signs d. Explain to the client and wife that they cannot sleep in the bed together
• ANSWER b. Close the door quietly and do not take any further action A male client with metastatic lung cancer has requested that " no heroic measures are used to extend his life ,so the healthcare provider prescribed transferring the client to the palliative care unit.Which action is most important to implement? a. Ensure the prescriptions for transfer include the clients end of life choice b. Flag the medical record for documentation of the clients PPOA c. Request a family member to gather the clients belongings d. Provide client with written info about palliative care
• ANSWER a. Ensure the prescriptions for transfer include the clients end of life choice While the nurse is assisting the healthcare provider with a sterile bedside procedure ,a code blue is called for another client on the unit who is experiencing a cardiac arrest. Which action should the nurse take? a. Respond to the code b. Close the room door c. Call for assistance d. Finish the procedure
• ANSWER d. Finish the procedure The nurse is caring for a group of clients on a surgical unit.Which action should the nurse implement first a. Direct the family members of a client in the operating room to the waiting area b. Assess a client who needs to be transferred to long term care

c. Obtain vital signs on an assigned client record ok the graphic sheet d. Determine if the client scheduled for surgery is prepared for the operating room – ANSWER d. Determine if the client scheduled for surgery is prepared for the operating room The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision. A, the number of clients leaving the unit for diagnostic tests B. the skill level of the personnel staffing the unit. C. the physician's plans to perform procedures on the unit D. the acuity level of the clients on the unit

• ANSWER D. the acuity level of the clients on the unit In planning care for a group of clients which task should the nurse delegate to UAP a. Reinforce teaching provided by the nurse about using call bell b. Remove the staples from clients week-old open to air incision c. Demonstrate the proper technique for using a walker d. Observe a client tele reading
  • ANSWER a. Reinforce teaching provided by the nurse about using call bell Which situation on an acute care inpatient surg unit requires intervention by the nurse manager? a. A staff nurse receives a verbal prescription from a surgical resident b. A student nurse administers a controlled substance supervised by preceptor c. A unit clerk receives a verbal telephone prescription from an attending healthcare provider d. A healthcare provider assistant writes prescription for an IV medication
  • ANSWER c. A unit clerk receives a verbal telephone prescription from an attending healthcare provider The ECG results revealed no active brain function for a client who had an ischemic cerebrovascular accident CVA. Five days ago. The client is being mechanically ventilated and is receiving IV fluids along with enteral tube feedings. The nurse and healthcare provider need to discuss the results of the ECG and the clients healthcare POA stating that the client is an organ donor. Which intervention should the nurse implement at the close of the meeting? a.Cancel all scheduled multidisciplinary care conferences B. Contact the state organs procurement agency C. Replace the endotracheal tube with a facemask D. Discontinue IV fluids and tube feedings
  • ANSWER B. Contact the state organs procurement agency In assigning client care to a PN ,it is most to assign which client to the nurse? The client who

a. Is two days post thyroidectomy and is unable to speak clearly due to laryngeal nerve damage b. Has diabetes and has an elevated serum glycosylated HGB(hgb a1c) c. Is newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine d. Is exhibiting signs of Addison's crisis after corticosteroids was discontinued - ANSWER b. Has diabetes and has an elevated serum glycosylated HGB(hgb a1c) The nurse manager decides to report a staff nurse to the peer review committee. Which activity merits this action? a. Change assignments without prior approval ' b. Wore a shirt with an obscene statement c.Administered two medications at the wrong time D. Documented before assessing clients

• ANSWER D. Documented before assessing clients The healthcare provider prescribed an oral medication to be given daily for three days .However the medication was also given on the fourth day .Which intervention is most important for the charge nurse to implement? a. Inform the pharmacist who is dispensed medication b. Report the medication error to the nursing supervisor c. A unit clerk receives a verbal telephone prescription from an attending healthcare provider c. Review the medication transcription with the nurse d. Evaluate the client for symptoms of drug interaction
• ANSWER d. Evaluate the client for symptoms of drug interaction This is the best action because it protects the client from harm and prevents further complications. The charge nurse should evaluate the client for symptoms of a drug overdose, such as nausea, vomiting, drowsiness, or respiratory depression, and administer antidotes or supportive measures if needed. After receiving morning report on an acute care unit , which client should the nurse assess first? a. A client who is shouting loudly because the breakfast trays have not arrived b. An immobile client who is innocent and has just spied his linen c. An elderly client whose children are concerned about the care their mother is receiving d. a client sitting close to the nurses station who has been restrained for the past - ANSWER d. a client sitting close to the nurses station who has been restrained for the past An older male client who has a hx of heart failure is admitted to the hospital after passing out while walking to the mailbox. The client is being treated with a cardiac glycoside ,diuretc , and restricted sodium diet. Which intervention is most important for the nurse to include in this clients plan of care? a. Teach about need for frequent rest periods

b. Daily 12 lead ECG c. Provide diet choices that are low in sodium d. Continuous electrocardiogram monitoring - ANSWER d. Continuous electrocardiogram monitoring Two clients in the ICU are assigned to an oncoming nurse at shift change. One client has pneumonia and is being mechanically ventilated , and the other had a thoracotomy yesterday and is currently complaining of incisional discomfort. Which action should the nurse take first? a. Complete head to toe physical assessment for the client with pneumonia b. Review plan of care priorities and meds due for both clients c. Administer PRN pain medication to the client with incisional discomfort d. Assess LOC and vital signs for both clients - ANSWER d. Assess LOC and vital signs for both clients At 0730 , two clients with diabetes mellitus need capillary blood glucose levels obtained and subcutaneous sliding scale insulin administration. The breakfast tray for the clients needs to be delivered. Which task should the nurse assign to the CNA? SATA a. Monitor a clients self administration of insulin b. Explain the purpose of sliding scale insulin c. Describe the symptoms of low blood glucose d. Perform the cap glucose measurements e. Deliver meal trays to clients with diabetes - ANSWER d. Perform the cap glucose measurements e. Deliver meal trays to clients with diabetes A male practical nurse PN is reluctant to use new blood glucose monitoring equipment despite having attended the mandatory in service about the equipment. Which action is best for the charge nurse to take? a. Observe the PN while he uses the new equipment b. Encourage the PN to use the old equipment until he gains confidence c. Assure the PN the he has the needed skills d. Demonstrate the procedure to the PN - ANSWER a. Observe the PN while he uses the new equipment Following a six week refresher course , a female nurse who has been out of the workforce for 10 years is assigned to a medical unit for orientation. After the first week of orientation , the charge nurse notes that the orientee is overwhelmed by her daily assignments, which are less than one half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week , which action is best for the charge nurse to take? a. Inform the supervisor that for a client safety this nurse should be assigned to a slower paced unit b. Talk to the orientee and ask her if she has considered working in a less stressful environment

c. Wait until the end of the second week to see if the orientee is able to complete her assignments d. Assign the orientee to work with an experienced nurse who is a long time, efficient employee - ANSWER d. Assign the orientee to work with an experienced nurse who is a long time, efficient employee The CNA reports to the nurse that a male client with fluid volume overload will not allow the CNA to obtain his daily weight. Which action should the nurse implement? a. Ask the client why he does not want to be weighed b. Direct CNA to delay weighing the client until later c. Instruct CNA to weigh the client using bed scale d. Document that the client refused daily weights - ANSWER c. Instruct CNA to weigh the client using bed scale A charge nurse agrees to cover another nurses assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch , which client should be checked first by the charge nurse? The client a. Admitted yesterday with DKA whose blood glucose level is now 195mg/dl (10.8mmol/L) b. Post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube c. With a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% d. With an ileal conduit created two days ago with a scant amount of blood in the drainage pouch - ANSWER c. With a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90% A new female employee reports to the charge nurse that she has developed a rash on her arms. What action is most important for the nurse to take? a. Suggest using a different soap for hand washing b. Ask the employee if she is allergic to latex c. Instruct the employee to complete an incident report d. Assess the employee for systemic allergic responses - ANSWER d. Assess the employee for systemic allergic responses A fire is reported in the kitchen on the first floor of a three floor community hospital , and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement? a. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators b. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits c. Instruct the UAPs to transfer all non-ambulatory clients via wheelchairs d. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives - ANSWER b. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits

A CNA is stuck in the palm of the hand by a needle that is found in the bed linen of a client diagnosed with Hep B. Which action should the charge nurse instruct the CNA to do first? a. Complete and file an incident report b. Report to the employee health nurse c. Wash hands with soap and water d. Have blood tests drawn per policy - ANSWER c. Wash hands with soap and water Which use of technology by the nurse is most likely to result in a violation of HIPPA? a. Clients are allowed access to their personal electronic health record b. Personal mobile devices are used to receive prescriptions from healthcare providers c. Digital photography is used to document wound healing in the electronic record d. Encrypted email used to communicate client data among the healthcare team - ANSWER b. Personal mobile devices are used to receive prescriptions from healthcare providers A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organizations budget. Which question is most important to consider when analyzing the cost benefit for this piece of equipment? a. Will the equipment require annual repair? b. Is the cost of equipment reasonable? c. How many departments can use the equipment? d. Can the equipment be updated each year? - ANSWER c. How many departments can use the equipment? An adolescent male is being transferred to the postoperative unit following an appendectomy. The postanesthesia care unit nurse reports to the nurse who is receiving the client that he has an IV of normal saline infusion at 125 ml/hr and receiving hydromorphone 2 mg IV 45 minutes ago is currently experiencing pain of 2 on a scale og 10. Ondanstron 4mg IV PRN every 4 hours is prescribed for nausea. Which additional client information should the nurse provide to complete this report? a. Refuses to take ice chips for complaints of dry mouth b. History of vomiting at home for 3 days prior to surgery c. Soft abdomen, absent bowel sounds, no bleeding on dressing d. Peripheral pulses present with full range of motion of both legs - ANSWER c. Soft abdomen, absent bowel sounds, no bleeding on dressing The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse? a. Reinforce client teaching for discharge to home b. Educate clients about prescribed dietary changes c. Establish blood pressure parameters for client monitoring d. Provide client with resources and discharge teaching - ANSWER a. Reinforce client teaching for discharge to home

Three days after a bowel ressection, an adult male requires oxygen at 4 liters per nasal cannula to keep his oxygen saturations at 92%. The client's lung sounds are decreased at the bases, and he has a weak ineffetcive cough. Which intervention is the MOST important for the nurse to include in the client's plan of care? a. Incentive spirometer every 2 hrs b. Increase the oxygen to 6 liters c. Keep the head of bed elevated d. Splint incision for deep breaths - ANSWER a. Incentive spirometer every 2 hrs In planning care on the nursing unit, which task is BEST to assign to the nurse (RN) rather than the practical nurse (PN) a. Remove staples and apply steri strips b. Irrigate an infected pressure ulcer c. Initiate a 24-hour urine collection d. Teach a client with diabetes to inject insulin - ANSWER d. Teach a client with diabetes to inject insulin A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admissions to the medical unit. The family presents the client a signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communitcation, which information should the nurse provide FIRST? a. Increasing confusion on the client b. Clients healthcare power of attorney c. Fall at home as a reason for admission d. Currently prescribed medicators - ANSWER a. Increasing confusion on the client A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. WHich intervention should the nurse implement? a. Advise the client to weigh all possible outcomes prior to decision b. Explain that the family has a right to know of potential health problems c. Suggest to the family the value of genetic screening d. Notify the health department of the client's condition. - ANSWER a. Advise the client to weigh all possible outcomes prior to decision Which staff assignment made by the primary nurse, requires the MOST immediate follow up action by the charge nurse on a medical unit? a. A practical nurse (PN) is assigned to mentor the blood pressure of a client with hypertension b. A practical nurse (PN) is assigned to transport a postoperative client to the rehabilitation unit c. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank

d. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction - ANSWER d. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction When providing care for clients on a surgical unit, which task can be delegated by the nurse to the unlicensed assistive personnel (UAP)? a. Replace the seal on a negative pressure wound vacuum b. Apply an abdominal binder over a client surgical incision c. Use a cotton-tipped applicator to insert wound packingd. d. d. Remove a wet-to-moist dressing application from a wound - ANSWER b. Apply an abdominal binder over a client surgical incision An adult woman with metastatic pancreatic cancer has requested tat no heroic measures are to be implemented to save her life. Instructors from the healthcare provider have been received to transfer the client to the palliative care room. What action is MOST important for the nurse to take? a. Take the family to the clients new room b. Give client written information about end of life care c. Give detailed report to accepting nurse d. Ensure transfer of the clients electronic chart code - ANSWER c. Give detailed report to accepting nurse Several Family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement.? a. Discuss why visitors should not lie in the bed with the client b. Notify the charge nurse that the visitor is lying on the client's bed c. Explain that the client has the right to have a visitor lie on the bed d. Instruct the UAP to ask the visitor to get off the client's bed - ANSWER c. Explain that the client has the right to have a visitor lie on the bed A client's laboratory test findings include a white blood cell (WBC) count of 1000mm^ (1x 10^9/L), hemoglobin 14 grams/dL(140g/L), hematocrit 42% (0.42), and potassium 3.5 mEq/L (3.5 mmol/L). After reporting the findings to the healthcare provider, which intervention should the nurse include in this client's plan of care? a. Space nursing care to provide rest periods b.Enforce meticulous hand washing C. Monitor symptoms of blood loss D. Record a 12 lead electrocardiogram daily - ANSWER b.Enforce meticulous hand washing A graduate nurse reports to the charge nurse that a postoperative clients blood pressure is 80/40 mmHg. Which question is most important for the charge nurse to ask ? a. What is the clients pulse rate b. What is the clients hemoglobin

c. Has the client recently been medicated for pain d. Is the client feeling dizzy - ANSWER a. What is the client's pulse rate While the registered nurse is preparing to take the vital signs of a newly admitted client with heart failure, a practical nurse enters the client's room and reports to the RN that another client just pulled out his central venous catheter and the unlicensed assistive personnel is in the room with the client. The RN knows that the newly admitted client is to receive a stat dose of an oral anti anxiety medication. How should the RN assign the needed care? - ANSWER C. The RNshould provide care for the client who removed the central venous catheter while the PN administers the stat medication and the UAP obtains the newly admitted client's vital signs. The nurse observes that the practical nurse has positioned a client for lumbar puncture by turning the client on the side with pillow under the clients head and the legs straight with pillow between the knees. Which action should the nurse take? a. Acknowledge that the PN has positioned the client safely and correctly b. Arrange for UAP to assist PN during the procedure c. Assume care of the client and assign the PN to the care of a different client d. Demonstrate to the PN how to position the client more effectively for the procedure - ANSWER d. Demonstrate to the PN how to position the client more effectively for the procedure The nurse is caring for a client at the clinic who test positive for a sexually transmitted disease. The client reports having sex with multiple partners. Which response should the nurse provide? a. Remain non-judgemental and assure the client of confidentiality b. Confirm that sexual activity may resume after innitial treatment c. Notify persons that STIs are reported to local health departments d. Provide counseling that most contraceptives protect against infection - ANSWER a. Remain non-judgemental and assure the client of confidentiality