HESI Leadership RN Samuel Merit Related

An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?

• A. Discuss with the family about placing the client in a skilled care facility.
• B. Determine if the client is manifesting other neurologic changes.
• C. Apply a restraining device to prevent the client from self injury.
• D. Request family members report when the client is left alone.

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 is assigned to transport a postoperative client to the rehabilitation unit.
• B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
• C. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
• D. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.

During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?

• A. Tell the healthcare provider the nurse will return the phone call as soon as possible.
• B. Remain with this client and monitor the vital signs while the nurse takes the call.
• C. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
• D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.

When making assignments for residents of a long-term care facility who require assistance with feeding, which client should the charge nurse assign to the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?

• A. An elderly woman who refuses to eat most meals served.
• B. A disabled client who is learning to use adaptive equipment.
• C. A client who drools but swallows solids after many attempts.
• D. An older, edentulous client who has loose fitting dentures.

An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take?

• A. Ensure transfer of the client's electronic chart code.
• B. Give a detailed report to accepting nurse.
• C. Give client written information about end-of-life care.
• D. Take the family to the client's new room.