HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded

HESI Concepts: Collaboration/Managing Care—Leadership, Infection Awarded 1.0 points out of 1.0 possible points.
4.ID: 8482539861The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: Call a poison control center Correct Administer an excessive amount of fluids to induce vomiting Call an ambulance to bring the child to the emergency department Leave a message at the physician answering service about the incident
Rationale: When a poisoning occurs, a poison center should be called immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested was a strong corrosive or petroleum product. Also, vomiting should not be induced unless a healthcare provider has given specific instructions to induce vomiting. Neither calling an ambulance nor calling the physician’s answering service is the immediate action, because either would delay treatment. Additionally, the physician would immediately make a referral to the poison control center. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should then call an ambulance.
Test-Taking Strategy: Note the strategic word “immediately” in the query of the question. First, recalling that vomiting should not be induced without appropriate advice to do so will help you eliminate the option that involves inducing vomiting. Next eliminate the options that will delay treatment (i.e., calling an ambulance and leaving a message with the answering service). Review immediate poison control measures if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal￾child nursing (3rd ed., pp. 120, 121). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points.
5.ID: 8482539830A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? Activating the agency disaster plan Correct Supplying the triage rooms with additional equipment Increasing the number of nursing staff for the day on which the hurricane is expected Calling the hospital maintenance department to secure the building against the storm
Rationale: In an external disaster, many people may be brought to the emergency department for treatment. Although increasing the nursing staff and supplying the triage rooms with additional equipment may be steps in preparing for casualties, the initial action by the nurse manager must be activation of the disaster plan. Calling the hospital maintenance department to secure the building from the storm is not a responsibility that falls within the scope of nursing management.
Test-Taking Strategy: Note the strategic word “first” in the query of the question. Use the process of elimination in determining the priority action. Note that the correct option is the umbrella option. Also remember that other necessary activities will be initiated once the agency disaster plan has been activated. Review procedures related to management in times of disaster if you had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety Awarded 1.0 points out of 1.0 possible points.
6.ID: 8482539863A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. “I need to follow the oxygen prescription exactly.” Correct “I can use my electric razor while I’m using oxygen.” “I have to keep the oxygen concentrator out of direct sunlight.” Correct “I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner.” “I have to tell everyone that they can’t smoke or have an open flame within 10 feet of the oxygen concentrator.” Correct
Rationale: The client should follow the oxygen prescription exactly. The use of electric razors or other equipment that could emit sparks should be avoided while oxygen is in use, because fire and injury to the client could result. The oxygen concentrator is kept out of direct sunlight and slightly away from walls and corners to permit adequate air flow. The client should not allow smoking or any type of flame within 10 feet of the oxygen source. Other measures include having telephone numbers for the physician, nurse, and oxygen vendor available and teaching the client signs and symptoms requiring emergency care.
Test-Taking Strategy: Recall that one hazard associated with oxygen is ignition, which could result from heat in the form of flames or sparks. Evaluating the question from this perspective, eliminate the options that are unsafe. Review oxygen safety measures if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 631). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Giddens Concepts: Client Education, Safety
HESI Concepts: Safety, Teaching and Learning/Client Education Awarded 3.0 points out of 3.0 possible points.
7.ID: 8482541877A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: Every 2 hours Correct