Hesi Leadership Exit Exam Version 1

1. The nurse is caring for an older adult who was admitted with a Urinary tract infection and is now exhibiting signs of Severe Inflammatory Response Syndrome (SIRS). Which collaborative care goals should the nurse include in the plan of care? (Select all that apply): BODY TEMP with in normal limits. REDUCE WBC count. NEGATIVE URINE CULTURE 2. The nurse is caring for clients on an orthopedic unit. Which client has the greatest risk for developing osteomyelitis?: OLDER ADULT W/OSTEOPOROSIS WHO IS BEDFAST FOLLOWING COMPRESSION FRACTURE OF THE VERTABRAE 3. . A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past 3 days as the result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital, Which intervention is most important for the nurse to include in this client's plan of care?: Initiate cardiac monitoring for the clients. 4. The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?: MUCOUS MEMBRANE MOIST 5. The nurse is caring for a group of five clients with the assistance of an experienced and capable unlicensed assistive personnel (UAP). Which nursing actions can the nurse delegate to the UP? (Select all that apply.): POST OP VITAL SIGNS HYGIENE CARE FOLLOWING TRAUMATIC FOOT AMPUTATION 6. When triaging emergency room clients, which client should the nurse assess first?: FEMALE WITH SEVERE RIGHT LOWER ABDOMINAL PAIN FEBRILE AND VOMITING *Confirm 7. While eating breakfast, a client admitted with syncope and a 2-month history of vertigo complains of dizziness. Using the standard communication tool SBAR (Situation, Background, Assessment, Recommendation), which statement is best for the nurse to provide the healthcare provider about the client's background?: The client's significant history includes atrial fibrillation and hypoglycemia. 8. Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits: BE AVAILABLE TO ALL SHIFTS TO DISCUSS CHANGES IN HEALTH BENEFITS 9. Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive one of the visitors is lying on the client's bed. Which action should the nurse implement?: EXPLAIN THE CLIENT HAS THE RIGHT TO HAVE VISITOR LIE ON THE BED 10. . The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day.: REVIEW MEDICATION TRANSCRIPTION WITH THE NURSE. 11. . The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called for another collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take: Respond to the code. OR Finish the procedure Not sure 12. Which client requires the most immediate intervention by the nurse?: - CLIENT WITH ACUTE KIDNEY INJURY who is somnolent and does respond to verbal commands. 13. . The nurse receives a telephone prescription from the healthcare provider for a client's persistent cough and wheezing, The prescription includes a chest xray, an antibiotic, and a nebulizer treatment now and PRN. Alter reading the prescription back to the healthcare provider to ensure accuracy, which intervention should the nurse implement first?: NEBULIZER BREATHING TREATMENT 14. An experienced, female practical nurse (PN) is hired to work on the surgical unit of a tertiary hospital. The first day she is working on the unit, the PN tells the charge nurse that she has excellent wound care skills. It is a busy day and a postoperative client needs to have a sterile dressing change. Which action is best for the charge nurse to take?: Watch the PN perform sterile wound care to validate her skill level 15. A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be "hooked up to any machines". His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm, respirations 30 breaths/minute, and oxygen saturation rate is 88%. Which action should the nurse take?: Discontinue the intravenous infusion 16. A child is admitted to the pediatric unit after being diagnosed with pertussis. The nurse observes an unlicensed assistive personnel (UP) donning on a pair of gloves before entering the room to give the child a popsicle. Which action should the nurse take?: REVIEW THE NEED TO WEAR A FACE MASK WHILE IN CLOSE CONTACT. 17. The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?: NOTIFY THE HEALTHCARE PROVIDER OF THE CLIENTS LACK OF UNDERSTANDING 18. A client with leukemia is hospitalized for weakness, fatique, and anemia. The client is restless and tachycardic. Which intervention is most important nurse to include in the plan of care?: MAINTAIN PROTECTIVE ISOLATION 19. An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which nurse should be responsible in coordinating the progression or this client's care through rehabilitation and discharge?: NURSE CASE MANAGER 20. When making assignments for residents of a long-term care facility who require assistance with FEEDING which client give to PRACTICAL NURSE and which client to licensed assistive personnel (UAP): Client who drools, but swallows solids after many 21. Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?: UAP IS ASSIGNED TO CHECK A CLIENT FOR FECAL IMPACTION 22. 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?: Advise to weigh all possible outcomes prior to the decision 23. . After an interdisciplinary team meeting regarding the client's request to die a natural death, the primary healthcare provider refuses to write the do-notresuscitate instructions. Which action should the nurse take?: Provide the healthcare provider with a copy of the client's bill of rights 24. The unlicensed assistive personnel (UP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to blain his dally weight Which action should the nurse implement?: Ask the client why he does not want to be weighed