HESI PN MED-SURGE EXAM

Question 1 The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What sh ...

Question 1 The nurse is providing care for a patient who is unhappy with the health care provider’s care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What should the nurse include in the documentation of this event in the patient’s medical record or on the AMA form? 1. Documentation that the patient was informed that he or she cannot come back to the hospital 2. Documentation that the patient was informed that he or she was leaving against medical advice 3. Documentation that the risks of leaving against medical advice were explained to the patient 4. Documentation of any discharge instructions given to the patient 5. Documentation indicating an incident report has been completed Correct Answer: 2,3,4 Rationale 1: It should be clearly documented that the patient was advised and understands that he or she can come back. Rationale 2: It should be clearly documented in the patient’srecord and on the AMA form that the patient was advised that he or she was leaving against medical advice. Rationale 3: It should be clearly documented that the patient understands the risks of leaving against medical advice. Rationale 4: The AMA form includes the name of the person accompanying the patient and any discharge instructions given. Rationale 5: Facility policy may require that an incident report be completed, but it must not be referenced in the chart. The patient’s record is a legal document, so the nurse should never document that he or she filed an incident report. Question 2 A nurse documents this statement in a patient’s medical record: “2/25/–, 2235. At 2015 patient awoke suddenly and complained ofshortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard.” This documentation meets which documentation guidelines? 1. Documentation is timely 2. Documentation is concise 3. Documentation is objective 4. Documentation includes date and time of entry 5. Documentation is complete and accurate Correct Answer: 2,3,4,5 Rationale 1: The nurse should document as soon as possible after an observation is made or care is provided. The entry was made in the patient’s medical record at least 2 hours after the patient complaint and should be labeled late entry. Rationale 2: This entry describes the situation fully but is concise. Rationale 3: The nurse describes factual events that can be seen, heard, smelled, or touched. It is important to be objective and avoid vague statements that are subjective. Rationale 4: Both the date and the time of the entry are documented. Rationale 5: The nurse should document only facts: what he or she can see, hear, and do. Question 3 A nurse documents the following in a patient’s medical record: “2/1/ , 1500. Patient appears weak and faint. Patient’s skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medication will be given.” This documentation meets which documentation principle? 1. Document objectively. 2. Do not document procedures in advance. 3. Use approved abbreviations. 4. Document changes in patient condition. Correct Answer: 4 Rationale 1: Documentation should be objective and avoid vague statements that are subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be described. The use of the word “appears” is subjective and could be manipulated later should the treatment or judgment be challenged. Rationale 2: The nurse has documented that pain medication will be given. This is documenting in advance. Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an abbreviation. “U” should be written out as “unit(s).” If unsure whether the abbreviation is correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be spelled out as “less than.” Rationale 4: In general, employers as well asstate, federal, and professional standardsrequire documentation to include initial and ongoing assessments, any change in the patient’s condition, therapies given and patient response, patient teaching, and relevant statements by the patient. Question 4 A nursing unit has changed its documentation system to documenting by exception. How will this system save time? 1. It eliminateslengthy or repetitive documentation. 2. It allowsflexibility and description in the documentation. 3. It allowsthe reader to easily locate information about a specific problem. 4. It allows for quick and easy retrieval of information. Correct Answer: 1 Rationale 1: Documenting by exception eliminates lengthy or repetitive documentation. Rationale 2: Flexible and descriptive documentation is an advantage of the narrative system. Rationale 3: PIE charting allows easy location of information about a specific problem. Rationale 4: The electronic health record allowsfor quick and easy retrieval of information. Question 5 A hospital is considering changing its documentation system to reduce the number of medication errors. Which system should the hospital investigate? 1. Problem, intervention, evaluation (PIE)system 2. Electronic medical record 3. Problem-oriented medical record 4. Narrative system Correct Answer: 2 Rationale 1: The PIE system consists of a list of the patient’s problems, interventionstaken to alleviate the problems, and evaluation of the patient’s response to the interventions. This system does not have the specific benefit of reducing medication errors. Rationale 2: The electronic medical record decreases errors and allows for the reconciliation of the patient’s medications on admission, daily, and on discharge. Rationale 3: The five components of the problem-oriented medical record are baseline data, a problem list, a plan of care for each problem, multidisciplinary progress notes, and a discharge summary. This system does not have the specific benefit of reducing medication errors. Rationale 4: Narrative documentation does not have the specific benefit of reducing medication errors. Question 6 Which nursing activities are examples of independent functions of the nursing role? 1. Teaching a soon-to-be-discharged patient about the medication regimen that the health care provider has prescribed 2. Talking with the patient about his or her abilitiesto manage personal hygiene activities while in the usual state of health at home 3. Incorporating adaptive techniques into nursing care as recommended by occupational therapy 4. Administering analgesic medication ordered by the health care provider 5. Introducing oneself to, and interviewing, the patient to collect data about physical health status Correct Answer: 2,5 Rationale 1: Teaching the patient about medications prescribed by the health care provider is an interdependent activity. Rationale 2: This activity is part of the assessment process, which is an independent activity that nurses may perform, based on their education and skills. Rationale 3: Working in coordination with another health team member is an interdependent activity. Rationale 4: Administering medication prescribed by the health care provider is an example of a dependent activity. Rationale 5: These activities are included in assessment, which is an independent activity that nurses may perform, based on their education and skills. Question 7 The nurse is caring for a 70-year-old patient who was just admitted to an inpatient rehabilitation center. The patient had required total parenteral nutrition for several days, but recently resumed and is tolerating a regular diet. She has another 4 days left in a course of intravenous antibioticsto complete treatment of a positive central line culture. Which nursing action, required in the care of this patient, is considered a dependent role function? 1. Requesting that the health care provider order a consult because the patient states that her dentures no longer fit properly and she has trouble chewing 2. Asking the nursing assistant to demonstrate to the patient how to operate the callsystem 3. Interviewing the patient to assess whether she needs assistance with getting out of bed 4. Administering the antibiotics prescribed by the health care provider Correct Answer: 4 Rationale 1: Assessing that the patient has a need that requires further assessment by other team members and communicating that need to the appropriate team member is an example of an interdependent activity. Rationale 2: This is an independent activity that nurses may perform or delegate, based on their and the delegate’s education and skills. Rationale 3: Assessment is an independent activity that nurses may perform, based on their education and skills. Rationale 4: Dependent activities are those prescribed by the health care provider and carried out by the nurse. Question 8 When asking a patient if a pain medication provided a few hours ago has been effective, the nurse is performing which step of the nursing process? 1. Planning 2. Implementation 3. Evaluation 4. Assessment Correct Answer: 3 Rationale 1: Planning consists of prioritizing among the chosen nursing diagnoses and determining interventions to move the patient to optimal health. Rationale 2: Implementation is the actual “doing” step of the nursing process. In this case, implementation occurred when the medication was administered. Rationale 3: Evaluation focuses on a patient’s behavioral changes and compares them with the criteria stated in the objectives. It consists of both the patient’s status and the effectiveness of the nursing care. Both must be evaluated continuously, with the care plan modified as needed. Rationale 4: Assessment comprises examining the patient and identifying cues, collecting and analyzing data, and reaching conclusions. In this situation, assessment occurred when the nurse identified that the patient was in pain. Question 9 The nursing instructor knows that further education is needed when a student makes which statement? 1. “Assessment precedes nursing diagnosis and outcome identification.” 2. “Planning follows nursing diagnosis and outcome identification and precedes implementation.” 3. “Evaluation followsimplementation and precedes planning.” 4. “Planning follows assessment and precedes evaluation.” Correct Answer: 3 Rationale 1: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 2: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 3: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Rationale 4: The correct order is assessment, diagnosis, planning, implementation, and evaluation. Question 10 A 16-year-old patient has been admitted for treatment of presumptive pelvic inflammatory disease. The patient’s hygiene is poor and she reports living “on the street” for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10 scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome statement is appropriate? 1. The patient’s comfort will be achieved and maintained. 2. The patient will be discharged to a safe living environment. 3. The patient will be reunited with her parents. 4. The patient’sinfection will be eradicated. Correct Answer: 1 Rationale 1: Achieving and maintaining comfort addresses the nursing diagnosis of acute pain related to possible pelvic inflammatory disease identified by the nurse. Rationale 2: The patient’s living environment is of concern but is not the correct outcome for the priority nursing diagnosis. Rationale 3: Reuniting the patient with her parents may not be a desired goal for this patient. It also does not match the nursing diagnosis chosen. Rationale 4: Eradication of the infection is a desired outcome but does not match the chosen nursing diagnosis. Question 11 While assessing a female patient from the Middle East, the nurse observes that the patient makes no eye contact and answers questions by nodding or with only a few words. The nurse’s entry in the patient’srecord statesthat the patient “appearsto be frightened.” This isan example of which factor associated with assessment? 1. Personal interpretation 2. Subjective data 3. Nursing diagnosis 4. Objective data Correct Answer: 1 Rationale 1: This is the nurse’s personal interpretation of the patient’s behavior. It has not been validated with the patient. These behaviors may indicate a number of possibilities such as physical, mental, and emotional status or cultural and social norms. Rationale 2: A direct quote from the patient would be subjective data. Rationale 3: This statement does not meet the criteria for a nursing diagnosis. Rationale 4: A description of the patient’s behavior such as “makes no eye contact” would be objective data. Question 12 The patient tells the nurse that everything “tastes funny” since starting a new medication, making eating unpleasant. The nurse has given this medication to other patients and has not heard this complaint from any of them. The nurse checks the drug reference again to learn whether this is a known side effect of the medication and reads that it is. This information may be helpful in making a nursing diagnosis and determining how best to address this problem. Which data from this scenario is considered subjective? 1. The nurse rechecks the drug reference about known side effects of the medication. 2. The patient tellsthe nurse that everything “tastesfunny.” 3. The nurse reads that this medication can cause a metallic taste in some patients. 4. Other patients who have taken this medication have never reported thisside effect to the nurse. Correct Answer: 2 Rationale 1: Rechecking the drug reference is an example of obtaining factual information about the medication, not data about the patient. Rationale 2: The statement by the patient is subjective data because it reflects something that only the patient, not the nurse, can perceive. Rationale 3: That this medication can cause a metallic taste is factual information about the medication, not data about the patient. Rationale 4: The nurse’s prior experience with this medication is not data about the patient. Question 13 Which statement represents a nursing diagnosis? 1. High risk for delayed maternal-infant bonding due to maternal-infant separation 2. Crohn’s disease 3. Hypertension 4. Appendicitis Correct Answer: 1 Rationale 1: This is an example of a nursing diagnosis. The statement indicates a clinical judgment that this new mother-baby couplet is at greater risk of experiencing a delay in bonding than other mother-baby couplets. Rationale 2: Crohn’s disease is a medical diagnosis. Rationale 3: Hypertension is a collaborative problem. Rationale 4: Appendicitis is a medical diagnosis.