HESI RN
HESI Leadership Questions
Extract:
Question 1 of 5
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
Question 2 of 5
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?
Correct Answer: B
Rationale: Observing the PN perform wound care ensures her skills meet standards, protecting client safety. Reviewing a checklist, dismissing experience, or delegating without verification are less effective.
Question 3 of 5
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?
Correct Answer: B
Rationale: Validating IV flow rates is within the PN's scope, involving routine checks of orders and drip rates. Initial wound care, assessing catheter need, and postoperative assessments require RN clinical judgment.
Question 4 of 5
A nurse who works in a long-term care facility is delegating aspects of client care to unlicensed assistive personnel (UAP). Which assignment(s) should the nurse delegate? (Select all that apply.)
Correct Answer: B,C
Rationale: Emptying an ostomy bag and providing a bed bath are routine tasks within the UAP's scope. Identifying lesions, performing foot care, and giving tracheostomy mouth care require clinical judgment and are RN tasks.
Question 5 of 5
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
Correct Answer: A
Rationale: Notifying the healthcare provider ensures prompt intervention to reverse anticoagulation and prevent bleeding. Monitoring, reporting, and testing are important but follow provider notification.