a nurse manager is considering how to implement a new policy on the unit which of the following best describes the process the nurse manager should fo
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HESI RN Nursing Leadership and Management Exam 5

1. When implementing a new policy on the unit, what process should a nurse manager follow?

Correct answer: A

Rationale: When introducing a new policy on the unit, it is essential for the nurse manager to involve staff members in the decision-making process. This approach helps in gathering input and insights from the team, fostering a sense of ownership and commitment. By communicating the reasons behind the policy change, the nurse manager ensures transparency and promotes understanding among the staff, leading to buy-in and acceptance of the new policy. Choice B is incorrect because implementing a policy change without involving staff and explaining the rationale may lead to resistance or lack of understanding. Choice C is not ideal as delegation without active involvement and communication with the team may result in misunderstandings or incomplete implementation. Choice D lacks the crucial step of involving staff in the decision-making process, which is important for successful policy implementation and team engagement.

2. The client with DM who is taking insulin develops a fever and becomes confused. Which action should the nurse take first?

Correct answer: A

Rationale: In a client with diabetes mellitus (DM) taking insulin, the development of fever and confusion may indicate hyperglycemia or diabetic ketoacidosis. Checking the blood glucose level is the priority action in this situation. This will help determine if the symptoms are related to high blood sugar levels, guiding further interventions. Administering a fever-reducing medication (choice B) addresses only the symptom of fever and does not address the underlying cause. Providing fluids to drink (choice C) is important but should come after addressing the potential hyperglycemia or diabetic ketoacidosis. Notifying the health care provider (choice D) can be important, but immediate action to evaluate and manage the client's condition should precede contacting the provider.

3. During the physical examination, Nurse Noah expects to assess which sign in a female client with a serum calcium level of 7.2 mg/dl?

Correct answer: A

Rationale: Trousseau's sign is a clinical indicator of hypocalcemia, characterized by carpal spasm when a blood pressure cuff is inflated above systolic pressure and maintained for a few minutes. This occurs due to increased neuromuscular irritability associated with low serum calcium levels. Homans' sign is used to assess for deep vein thrombosis and involves calf pain upon dorsiflexion of the foot. Hegar's sign is a softening of the lower uterine segment seen in pregnancy, while Goodell's sign is softening of the cervix also seen in pregnancy. Therefore, in this scenario, the correct assessment related to hypocalcemia would be Trousseau's sign.

4. The client with newly diagnosed diabetes mellitus is being taught about managing blood glucose levels. Which statement indicates a need for further teaching?

Correct answer: C

Rationale: Choice C indicates a need for further teaching because stating 'I can eat unlimited fruit as it is healthy' is incorrect. While fruits are healthy, they also contain natural sugars that can affect blood glucose levels. Portion control is crucial to managing blood glucose levels effectively. Choices A, B, and D demonstrate correct understanding. Rotating insulin injection sites helps prevent tissue damage, monitoring blood glucose levels before meals aids in managing diabetes effectively, and carrying a fast-acting carbohydrate is essential to treat hypoglycemia promptly.

5. A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is:

Correct answer: B

Rationale: The correct answer is B: 6-14 hours after administration. NPH insulin has an onset of action within 1-2 hours, a peak action at 6-14 hours, and a duration of action of 16-24 hours. The peak action period, which is when the risk of hypoglycemia is highest, falls between 6-14 hours after administration. Choices A, C, and D are incorrect because they do not align with the typical action profile of NPH insulin.

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