Hesi

Question 1

A policy requiring the removal of acrylic nails by all nursing personnel was implemented six months ago. Which assessment measures best determine if the intended outcome of the policy is being achieved.

Answer 1

Healthcare associated infection rate is lowered

Question 2

How do you collect a 24 hour urine collection?

Answer 2

Discard the first avoid, then collect all your avoided in the next 24 hours. Container must be refrigerated.

Question 3

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L per minute. To assess for skin damage related to the cannula, which areas to the nurse observe?

Answer 3

Top of the ears, and around the nostrils

Question 4

A client who has a BMI of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend?

Answer 4

Keep a record of food and drinks consumed daily

Question 5

The nurse explains to an older male the procedure for collecting a 24 hour urine specimen for creatinine clearance

Answer 5

Empty the urinal contents into the 24 hour collection container after the first void of the morning

Question 6

The nurse observes a unlicensed assistive personnel, who is providing a total bed bath for a confused and lethargic patient. The UAP is soaking the clients foot in a basin of warm water placed on the bed. What action should the nurse take?

Answer 6

Remind the UAP to drive between the clients toes completely

Question 7

The nurse in the emergency department observes, a colleague, viewing the electronic health record of a client who holds an elected position in the community. The client is not part of the colleagues assignment. What action should the nurse implement?

Answer 7

Communicate the colleagues action to the unit charge nurse

Question 8

An elderly client with a fractured left hip is on strict bed rest. Which nursing measure is essential to the clients nursing care.

Answer 8

Gently lift the patient when moving into a desired position to avoid sharing forces when repositioning

Question 9

The nurse is administering medication through a NG tube, which is connected to suction. After ensuring, correct tube placement, what action should the nurse take next?

Answer 9

Flush the tube with water, NGT tube should be flush before, after, and in between each medication admin

Question 10

A client who is in hospice care, complains of increasing amount of pain. The healthcare provider prescribes, and analgesic every four hours as needed. Which action should the nurse implement?

Answer 10

Give a around the clock schedule for admin of analgesics

Question 11

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand or blue. What action should the nurse implement first

Answer 11

Loosen the right wrist restraints

Question 12

Primary purpose of evidence based research in nursing

Answer 12

Using results from research to improve the outcome of nursing care

Question 13

Proper use of a metered dose inhaler to ensure optimal benefits of the drug

Answer 13

Compress the inhaler while slowly breathing in through your mouth

Question 14

Implementing interventions that focused on protecting a client from physical and emotional harm

Answer 14

Safety and security needs

Question 15

Health illness, continuum model

Answer 15

Patient goes from being really sick and depressed to feeling better than ever

Question 16

One of the main reasons for conducting nursing research

Answer 16

Generate knowledge to guide practices

Question 17

Erickson theory

Answer 17

Based on psychosocial development on the process of socialization, and how individuals interact with the world

Question 18

Final step of the evidence based practice model

Answer 18

To evaluate practice changes

Question 19

What would be an example of the nurse practicing Fidelity?

Answer 19

Stays with the client during death, as promised

Fidelity requires the nurse to keep promises, made, and be faithful to one’s commitments

Question 20

A client is in a persistent, vegetative state, following a severe motor vehicle accident. The client has no immediate family. Whom should the nurse consult one taking direction for Care?

Answer 20

A surrogate decision maker

Patients that have severe cognitive impairment, or who are incapacitated, or vegetative state, or, do not have capacity to participate in decision, making about their healthcare. Surrogate decision maker, must legally be designated to act on their behalf.

Question 21

A nurse is working at a clinic that serves a Community with a high population of immigrants. Which nursing assessment is the priority.

Answer 21

Language assessment

for communication, obtain a interpreter

Question 22

Nurses complete incident reports as dictated by the agency protocol. What is the primary reason nurses fill out an incident report?

Answer 22

To improve quality of care

Incident reports are not designated to be means for disciplinary action, but are designed to identify actual or potential risk that can be addressed to improve quality of care

Question 23

The nurse is talking with a client who is thinking about obtaining a second opinion regarding the surgeons recommendation for surgery which response by the nurse is considered an advocacy response

Answer 23

Let us know if we can answer any further questions after you obtain your second opinion

Offering support and further assistance as well as information. Represents an advocacy response.

Question 24

The nurse helps a patient for breakfast and then tells the patient I’ll be back. In the meantime here’s your call in case you need me. What is the nurse demonstrating?

Answer 24

Fidelity

Fidelity involves keeping promises and being faithful to the promises, the nurse makes

Question 25

Ethical distress is

Answer 25

Knowing the correct action, but being unable to perform at due to constraints

Question 26

The nurse obtains an order for a bad alarm for a confused patient this is an example of which ethical principle

Answer 26

Paternalism

Making a decision for a client who is confused to prevent an injury, is an example of paternalism

Question 27

Ethnocentrism is

Answer 27

Viewing one’s own culture as the only one correct standard

Question 28

A staff nurse works on a medical unit were staff retention is very high. There is a sense of equality between the leader and a staff nurse. The unit decisions and activity are shared between leader and the group. It does need a nurse leader practices, which leader ship style.

Answer 28

Democratic

Question 29

The nurse is caring for a client with a new diagnosis of osteoarthritis and degenerative joint disease. Which action should the nurse perform when addressing the clients cognitive learning needs

Answer 29

Educate the client about the pathophysiology of the disease process

Cognitive learning theory is a result of people wanting to make sense of the world around them

Question 30

Which documentation example best reflects the complexity of client teaching by the nurse

Answer 30

A client in spouse taught how to use phone app to count carbohydrates client return demonstrated carb counting for hypothetical meal

The nurse document who the teaching was provided to, and what was taught, the teaching method and evidence of learning

Question 31

While applying dressings to a clients wound the nurse teaches the client about with Care. To promote the most effective, teaching learning relationship with this client what would be most important for the nurse to keep in mind

Answer 31

The nurse and client relationship is based on mutual sharing and negotiation