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
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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?

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. A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?

Correct answer: D

Rationale: The appropriate response acknowledges the client's concern and confirms that they have the right to change their mind.

3. A patient is admitted to the emergency department with hypovolemia. Which IV solution should the nurse anticipate administering?

Correct answer: D

Rationale: Lactated Ringer's solution is the most suitable IV solution for a patient with hypovolemia. It is a balanced crystalloid solution containing electrolytes such as sodium, chloride, potassium, calcium, and lactate, which closely resemble the body's natural fluids. This solution helps to restore intravascular volume and electrolyte balance in hypovolemic patients. Choice A, 3% sodium chloride, is a hypertonic solution used for specific situations like severe hyponatremia or cerebral edema, not typically for hypovolemia. Choice B, 10% dextrose in water, is a hypertonic solution primarily used for providing calories and free water, not for volume expansion. Choice C, 0.45% sodium chloride, is a hypotonic solution used for conditions like hypernatremia or as maintenance fluid, not for hypovolemia.

4. Which atrioventricular heart block is also referred to as Mobitz II?

Correct answer: B

Rationale: The correct answer is B. Second-degree atrioventricular heart block is also known as Mobitz II. In Mobitz II, some atrial impulses are blocked from reaching the ventricles, resulting in occasional dropped beats. Third-degree atrioventricular heart block is known as complete heart block, where no atrial impulses reach the ventricles. First-degree atrioventricular heart block is a condition where there is delayed conduction between the atria and ventricles but all atrial impulses are eventually conducted to the ventricles.

5. Which of the following best describes evidence-based practice?

Correct answer: C

Rationale: Evidence-based practice involves integrating clinical expertise with the best available evidence to make informed decisions about patient care. Choice A is incorrect as evidence-based practice relies on current and relevant research. Choice B is incorrect as it emphasizes the importance of not relying solely on personal experience. Choice D is incorrect as patient preferences play a significant role in evidence-based practice.

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