a nurse is preparing to delegate bathing and turning of a newly admitted client who has end stage cancer to an experienced assistive personnel ap whic

HESI LPN

Leadership and Management HESI Quizlet

1. A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-stage cancer to an experienced assistive personnel (AP). Which of the following assessments should the nurse make before delegating care?

A. Is the client's family present so the AP can show them how to turn the client?
B. Has data been collected about specific client needs related to turning?
C. Does the AP have time to change the client's central IV line dressing after turning her?
D. Has the AP checked the client's pain level prior to turning her?

Correct answer: B

Rationale: Before delegating the task of bathing and turning a client with end-stage cancer to an experienced assistive personnel (AP), the nurse must assess specific client needs related to turning. This assessment ensures that the delegated care is tailored to the client's individual requirements, promoting safe and effective care. Option A is incorrect because the presence of the client's family is not directly related to assessing the client's specific needs for turning. Option C is incorrect as it refers to a different task (changing the central IV line dressing) and is not directly related to the turning assessment. Option D is incorrect as checking the client's pain level, although important, is not directly related to the specific needs related to turning the client.

2. What does the mnemonic PERLA stand for in the assessment of the eyes?

A. Pupils equally reactive to light and accommodation
B. Patient eyes are equally recessed and responsive to light and acuity
C. Patient eyes are equally responsive to light and acuity
D. Pupils equally reactive to light and acuity

Correct answer: A

Rationale: The correct answer is A: 'Pupils equally reactive to light and accommodation.' PERLA is a mnemonic used in eye assessments to check for Pupils being equally reactive to Light and Accommodation. Choice B is incorrect as it includes irrelevant information about the eyes being recessed. Choice C is incorrect as it is missing the mention of pupils and accommodation. Choice D is incorrect as it misses the mention of accommodation.

3. Which statement about appendicitis is accurate and true?

A. Appendicitis is more common among females than males.
B. A high fiber diet is a risk factor associated with appendicitis.
C. Left lower quadrant pain is suggestive of appendicitis.
D. McBurney's point tenderness is suggestive of appendicitis.

Correct answer: D

Rationale: The correct answer is D: McBurney's point tenderness is suggestive of appendicitis. McBurney's point is located in the right lower abdomen and tenderness at this point is a classic sign of appendicitis. Choice A is incorrect as appendicitis is slightly more common in males than females. Choice B is incorrect as a high fiber diet is actually considered to be protective against appendicitis. Choice C is incorrect as appendicitis typically presents with pain in the right lower quadrant, not the left.

4. A nurse is receiving a verbal prescription from the provider for a client who is experiencing increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?

A. Morphine sulfate 10 mg IV q 4 IV prn for pain
B. MS 10 mg IV every 4 8 prn for pain
C. MSO4 10 mg IVP q 4 8 prn for pain
D. Morphine sulfate 10.0 mg every 4 hours IV prn for pain

Correct answer: A

Rationale: The correct transcription is 'Morphine sulfate 10 mg IV q 4 IV prn for pain.' In choice A, 'Morphine sulfate 10 mg IV q 4 IV prn for pain' correctly indicates the medication, route (IV), frequency (every 4 hours), and administration as needed for pain control. Choice B is incorrect as 'MS' is not a standard abbreviation for Morphine Sulfate, and the frequency 'every 4 8' is not a valid time interval. Choice C is incorrect as 'MSO4' is not the standard abbreviation for Morphine Sulfate, and 'IVP' is not the standard route abbreviation for intravenous. Choice D is incorrect as it lacks clarity with '10.0 mg' instead of '10 mg,' and the frequency is given as 'every 4 hours' without specifying the route of administration.

5. What is the significance of patient advocacy in nursing?

A. Prioritizing the needs of the healthcare team over the patient
B. Ensuring that patients' rights and preferences are respected
C. Limiting patient autonomy
D. Focusing solely on clinical procedures

Correct answer: B

Rationale: Patient advocacy in nursing entails ensuring that patients' rights and preferences are respected. This involves advocating for the patients' best interests, supporting informed decision-making, and safeguarding their autonomy. Choice A is incorrect because patient advocacy focuses on the patient's needs, not the healthcare team's. Choice C is incorrect as patient advocacy aims to empower patients and enhance their autonomy rather than limiting it. Choice D is incorrect since patient advocacy goes beyond clinical procedures to encompass holistic care that addresses the patients' preferences and rights.