a nurse is preparing to discharge a client who as end stage heart failure the clients partner tells the nurse she can no longer handle caring for the a nurse is preparing to discharge a client who as end stage heart failure the clients partner tells the nurse she can no longer handle caring for the
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Nursing Elites

HESI LPN

Leadership and Management HESI Quizlet

1. A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The nurse should contact the case manager to discuss discharge options and support the client's partner. This action is appropriate as it involves seeking professional guidance and support for the client's partner who is struggling to care for the client. Option A is not the best choice as it solely focuses on involving another family member without addressing the partner's concerns directly. Option B is premature as recommending long-term care should be a well-considered decision involving multiple healthcare professionals. Option D delays the inevitable without providing a solution to the partner's current challenges.

2. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

3. How should a healthcare provider respond to a parent concerned about their child's sleep pattern?

Correct answer: C

Rationale: When a parent expresses concerns about their child's sleep pattern, providing education on sleep hygiene is a beneficial response. Teaching parents about establishing a consistent sleep routine, creating a conducive sleep environment, and promoting healthy sleep habits can help address the child's sleep issues. This empowers the parent to make positive changes that can improve the child's sleep patterns. Recommending a sleep study (Choice A) may be premature and unnecessary without first addressing basic sleep hygiene. Suggesting increasing daytime naps (Choice B) may not always be appropriate and could further disrupt the child's nighttime sleep. Advising on medication use (Choice D) should be considered only after other non-pharmacological approaches have been tried and if deemed necessary by a healthcare provider.

4. Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 90 beats/min. What is the most appropriate initial management for this newborn?

Correct answer: A

Rationale: A heart rate below 100 beats/min in a newborn indicates the need for positive pressure ventilation to improve oxygenation. Providing positive pressure ventilations helps in assisting the newborn's breathing efforts to ensure adequate oxygenation. Choice B, providing blow-by oxygen, may not be sufficient to address the underlying issue of inadequate breathing. Choice C, assessing the newborn's skin condition and color, is important but not the most immediate action needed for a heart rate below 100 beats/min. Choice D, starting chest compressions, is not indicated as the infant is breathing spontaneously and has a heart rate, albeit lower than normal, which does not warrant chest compressions.

5. How should the nurse measure urinary output for an infant with dehydration?

Correct answer: C

Rationale: The correct way to measure urinary output for an infant with dehydration is by weighing the diaper. Wet diapers are weighed to assess the amount of output accurately. Attaching a urine collecting bag and inserting a catheter are invasive methods not typically used for routine measurement of urinary output in infants. Wringing out the diaper can lead to inaccurate measurements and is not a recommended method for assessing urinary output.

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