LEADERSHIP/MGMT 2016 HESI EXAM

1.Charge nurse takes over for nurse on break, which client checked first

-40ml dark colored urine

2. UAP stuck in palm by needle with Hep B

-wash hands with soap and water

3. Assess first

-coronary syndrome with increasing SOB

4. New clinical documentation

-Need to discuss new clinical documentation that helps save lifes and require one more document

5. PCA to PO. BP increases 120/72 to 150/90. Additional questions/comments to HCP

-can PCA be reinitiated

6. Most immed, intervention by nurse

-pneumothorax with 80 o2

7. Intervention best to delegate to LPN

-duragesic

8. Morning lab, follow-up first

-BNP assay, MI with SOB 1000

9. UAP to assemble nephrostomy tube

-change bag to leg bag

10. Women health fair, PN helping RN

-assist with bone density prep

11. Warrants immediate attention

-female with RLQ pain in abd, febrile and vomiting

12. Delegated to UAP

-apply abd binder

13. Multidisplinary team

-elderly man with BGL 400

Assess first

-constipation

-weakness

-pressure ulcer with skin flap

-hep A

14. Triaging ER client assess first

-elderly

-child

-female

-male

15. 67 y/o female client recently widowed, increased confusion/disorientation.

-medical eval, managed healthcare plan

16. Female resident who is mentally alert and lives in a long-term care facility reports that a staff
member slapped her

-does she know the name of the person

17. Most important to assign which client to a RN rather than PN

-Pain scale of 9

18. PN reports to RN, patient pulled out CVC, UAP is with him in room. Stat dose of oral antianxiety med.
RN assign care

-RN with CVC, PN stat med, UAP VS on new admission

19. Charge nurse is making assignments for a 15 bed skilled nursing unit with staff of one RN, 2 LPNs,
and 2 UAPs which assigned to RN

20.Order women with history of HTN transferred from long-term to ICU b/c of HF, has DNR (SATA)

-BP, MAP 92

-body weight daily

-prepare family for end of life

-monitor urine

21. RN assigned to care for four surgical clients. Which client should nurse see first.

-3 postop, 1 preop

22. The nurse is caring for a group of clients on a surgical unit. What action should the nurse implement
first

-prepared for OR

23.0200 nurse phones HCP to request med for client who is unable to sleep four times the the dose.
Nurse questions, HCP sleepy says “yea, ok” action first

-call HCP about dosage

24. Watches UAP bring soap, washcloths, and towels and a basin into room with male client who has
suprapubic catheter inserted earlier today.

25. Telephone triage at clinic office. Which client is most acute and should be scheduled for the first
available appointment.

-21 y/o with kidney transplant, fever of 102, flu-like symptoms

26. Nurse should assess the client with which problem first

-arterial occlusion

27. RN gathering supplies to assist HCP with bedside thoracentesis when ED calls to report on a client
with unstable angina

-PN assist with thoracentesis, RN gets report, UAP prepares room

28. UAP give bath and change bed linen on Kaposi sarcoma (associated with HIV)

-tell UAP to wear gloves and gown when handling linen

29. Safely assess last drainage

-Jackson-Pratt, no postop drainage after 8 hours

30. Postop RR decrease from 14 to 6 after opioid. 30 minutes later decreases to 4. Narcan given

-why wait so long to call HCP

31. Nurse determines that an IV vesicant chemo infusion is infiltrated

-apply cold compress

32. Nurse planning care for 4 postop clients, different drainage systems

33. 5 y/o boy with mumps is transferred to the peds unit. Nursing intervention most important to
implement?

-PPE cart placed in front of the clients door

34. Evening shift on med unit is busy, only nurse on the unit is busy with an unstable patient. HTC is on
the phone with the unit secretary for an order for OTC laxative PRN. What is the best response?

-the nurse will call you back as soon as possible to obtain the order

35. Elderly male who is ketoacidotic becomes agitated when the nurse attempts to orient the client to
time and place. What room is the best for this client?

-the room next to nurses station

36. Pt diagnosed with unstable angina is scheduled for cardiac cath. Select all.

-assess chest pain or armpit pain, check pulses on both feet, assess groin access site, monitory VS per
post op protocol.

37. Nationally known management consultant is expensive and is here to give a presentation at a local
hospital. What is the best way to make sure that the information is received and passed onto other staff
members?

-send 2 nurses to get information

38. Making assignments for the day, which info provided during change of shift report is most important
for the charge nurse to consider?

-elderly female client who refuses to be cared for by a male nurse

39. Patient being transferred from PACU, what would finish the report… cardiac patient

-when was the last narcotic given

40. Patient being transferred from PACU, what would finish report

-absent bowel sounds..

41. PN observes that LPN performed a dressing change. But when the PN goes the check the patient she
notices that the dressing is 2 days old. What should the PN do first?

-consult the LPN about the discrepancy

42. Which client is assessed first at the beginning of the shift

-acute abdominal pain

43. Iv on male client admitted with sepsis. UAP told to get VS. UAP reports that skin is flushed and dry
with temp of 102 HR 120, RR 24. What should the nurse delegate to the UAP

-ask client if in pain

44. UAP has restrained a female client to a wheel chair and the client is asking to be untied. The UAP
explains to the nurse that this is the only way she can put new sheets on the patient’s bed. What action
should the CN take?

-advise the UAP to remove the restraints immediately

45. Charge nurse is making assignments in an inpatient psych unit. Which task should be given to the
LPN

-admin of routine meds

46. Upon morning shift, which patient do you assess first

-40 y/o with triple A and low back pain

47. Which can the LPN do? (THESE ARE NOT THE ANWERS)