HESI Leadership RN Samuel Merit

Extract:

Question 1 of 5

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?

Correct Answer: B

Rationale: Assessing for neurologic changes identifies potential causes of agitation, such as delirium or hypoxia.

Question 2 of 5

Which client requires the most immediate intervention by the nurse?

A. A client with acute kidney injury who is somnolent and does not respond to verbal commands. B. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6 F (38.1 C). C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus. D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.

Correct Answer: A

Rationale: Somnolence in acute kidney injury suggests uremic encephalopathy, requiring immediate neurological assessment.

Question 3 of 5

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

A. Discuss why visitors should not lie in the bed with the client. B. Notify the charge nurse that the visitor is lying on the client's bed. C. Explain that the client has the right to have a visitor lie on the bed. D. Instruct the UAP to ask the visitor to get off the client's bed.

Correct Answer: D

Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.

Question 4 of 5

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

A. Place an isolation cart outside of the room to initiate droplet precautions. B. Schedule bedside play time with the occupational therapist. C. Instruct the child's parents about the need for transmission precautions. D. Assign the child to a room close to the nurse's station.

Correct Answer: A

Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control.

Question 5 of 5

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.

Correct Answer: A

Rationale: The client refusing meals requires a PN's assessment to address potential psychological or physiological issues.