Evolve HESI Leadership/Management - Questions, Answers and Rationales

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Evolve HESI Leadership/Management - Questions, Answers and Rationales A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes s... erosanguineous drainage on the abdominal dressing. What is the next nursing action? 1 Change the dressing. 2 Reinforce the dressing. 3 Replace the tape with Montgomery ties. 4 Support the incision with an abdominal binder. The nurse should anticipate drainage and reinforce the surgical dressing as needed. Changing a dressing at this time is unnecessary and increases the risk for infection. Montgomery ties are used when frequent dressing changes are anticipated; they are not appropriate at this time. An abdominal binder rarely is prescribed, and it will interfere with assessment of the dressing at this time. Which are considered as nurse competencies within the synergy model of care delivery? Select all that apply. 1 Collaboration 2 Care planning 3 Communication 4 Clinical judgment 5 Cultural competency The Synergy Model describes eight nurse competencies, which include collaboration, clinical judgment, advocacy and moral agency, caring practices, facilitation of learning, systems thinking, response to diversity (cultural competency), and clinical inquiry. Care planning and communication are skills that every nurse should demonstrate regardless of the care delivery system being implemented. Which are the highest priorities when conducting a primary client survey during the emergency assessment? Select all that apply. 1 Airway 2 Disability 3 Breathing 4 Circulation 5 Cervical spine Airway and stabilization of the cervical spine are the top priorities when conducting a primary client survey during the emergency assessment. The nurse will then focus on breathing, circulation, and disability. The charge nurse is identifying tasks for staff caring for clients using functional nursing. Which tasks should be assigned to the licensed practical/licensed vocational nurse (LPN/LVN)? Select all that apply. 1 Showering two clients after breakfast 2 Administering topical and oral medications 3 Providing discharge instructions to three clients 4 Measuring capillary blood glucose level for five clients 5 Identifying nursing diagnoses after analyzing collected data Task assignments are made according to scope of practice. For the LPN/LVN, the scope of practice would include administering topical and oral medications and measuring capillary blood glucose levels. Showering would be a task assigned to unlicensed assistive personnel (UAP). Providing discharge instructions and identifying nursing diagnoses would be assigned to the registered nurse (RN). The case manager notes that a client's hospitalization is being prolonged for one day because of an unexpected adverse medication reaction. What action should the case manager take? 1 Add the extra day into the pathway. 2 Document the reaction as a variance. 3 Change all uses of the pathway to add the extra day. 4 Prepare documentation to submit to Medicare about the extra day. If a client's progress deviates from the normal path, a variance is indicated. A variance is anything that occurs to alter the client's progress through the normal critical path. The reason(s) for the variance should be analyzed and the care revised to meet the needs of the clients. An extra day is not added into the pathway and all uses of the pathway are not changed by adding an extra day based on this single variance. There is no evidence to support that the case manager needs to submit documentation to Medicare about the extra day. Which skills are essential for the nurse who is setting priorities for client care? Select all that apply. 1 Evaluation 2 Assessment 3 Critical thinking 4 Case management 5 Clinical decision-making Essential skills for the nurse who is setting priorities for client care include assessment, critical thinking, and clinical decision-making. Evaluation and case management are nursing skills; however, these are not essential for setting priorities. The nurse is performing resuscitation interventions for airway, breathing, and circulation as part of a primary survey in a client. Which order of actions should the nurse follow for this client? 1. Use direct pressure for external bleeding. 2. Prepare for chest decompression if needed. 3. Assess breath sounds and respiratory effort. 4. Establish airway by positioning, suctioning, and oxygen as needed. 5. Maintain vascular access using a large-bore catheter. 1.Establish airway by positioning, suctioning, and oxygen as needed. 2.Assess breath sounds and respiratory effort. 3.Prepare for chest decompression if needed. 4.Maintain vascular access using a large-bore catheter. 5.Use direct pressure for external bleeding. The primary survey includes assessment of airway/cervical spine, breathing, circulation, disability, and exposure. First, the nurse should establish airway patency by positioning, suctioning, and providing oxygen as needed. Assess breath sounds and respiratory effort and provide chest decompression if needed in order to assess breathing. Maintain vascular access using a large-bore catheter and use direct pressure for any external bleeding. What is the priority nursing care for a client who is prescribed hydroxychloroquine (Plaquenil)? 1 Teaching the client to report blurred vision 2 Teaching the client to report signs of infection 3 Teaching the client to report shortness of breath 4 Teaching the client to report stomach discomfort Plaquenil is a hydroxychloroquine used to treat rheumatoid arthritis. The adverse effect of Plaquenil is retinal damage; therefore, a client on Plaquenil is taught to report blurred vision. A client on steroids is taught to report signs of infection. A client on infliximab is taught to report shortness of breath. Plaquenil causes mild stomach discomfort, which is normal and is not related to priority nursing care. [Show More]

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