Leadership Management HESI EAQ
The nurse is caring for a client with breathing difficulty and is unable to auscultate any breath sounds on one side.
... [Show More] Which action should be implemented first by the nurse?
The priority care for clients with breathing difficulties who present with absent breath sounds is a needle thoracostomy. This procedure involves removing the fluid or abnormal air from the pleural space. Intubation is done for the client in severe respiratory distress. Supplemental oxygen should be given to the client with decreased oxygen saturation levels. Ventilation with a bag valve mask is given to clients if respirations are inadequate or absent.
A hospital's emergency power generators were accidentally destroyed. The hospital management has decided to move the clients to another hospital. Which staff interventions are appropriate to ensure client safety? Select all that apply.
Damage to power generators is an example of an internal disaster that can pose danger to clients. Shifting clients to another hospital can help reduce the risk. Hospital staff should carry flashlights to ensure adequate lighting during the move and avoid injuries to clients and themselves. The hospital staff should use staircases to shift clients as the elevators would be non-functional due to power loss. The hospital staff would ideally wear headlamps if they are available as these can provide hands-free lighting. Glow sticks provide lighting and can be used while shifting clients. As previously mentioned, elevators are nonfunctional in the event of power loss and would not be used.
Which priority interventions should be followed by the nurse when caring for a client with malignant hyperthermia? Select all that apply.
The client should be ventilated with 100% oxygen using the highest possible flow rate when malignant hyperthermia is evident. The client should be intubated immediately with an endotracheal tube. All inhalation anesthetic agents should be stopped immediately as the client's condition may worsen. The core body temperature should be monitored on an ongoing basis (wrong). An indwelling urinary catheter is inserted to monitor urine output, which is part of ongoing monitoring (wrong).
The nurse is assisting the registered nurse with delegation decisions regarding management of a client with shortness of breath. Which action by the nurse indicates a need for correction?
The nurse may not provide constructive feedback about the client care management during delegation decisions. The nurse may, however, provide constructive feedback to the delegatee to maximize the efficiency of the client care. The nurse may assist other registered nurses with delegation decisions by using three strategies: asking, offering, and doing. Asking involves inquiring about the client care problems and issues such as the respiratory rate. Offering involves suggesting ways to achieve desirable client care outcomes, such as asking the client to perform breathing exercises regularly. Doing involves demonstrating the specific task to improve client care—for instance, administering oxygen to the client. [Show Less]