Module 5 Exam: HESI VN TXGRP

Module 5 Exam: HESI VN TXGRP 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 1/117 Question 1 1 / 1 pts A client with le ...

Module 5 Exam: HESI VN TXGRP 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 1/117 Question 1 1 / 1 pts A client with leukemia is being considered for a bone marrow transplant. The health care team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of health care ethics is the team practicing? Justice Fidelity Autonomy Correct! Correct! Nonmaleficence Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in health care ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Health care professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other health care professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Use knowledge of the subject to help you with the process of elimination. Think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of health care ethics if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 2/117 Question 2 1 / 1 pts Which action by the nurse represents the ethical principle of beneficence? The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. The nurse follows a plan of care designed to relieve pain in a client with cancer. The nurse administers an immunization to a child even though it may cause discomfort. Correct! Correct! The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 3/117 Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other health care professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of health care ethics if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? Performing a procedure without consent Correct! Correct! Telling the client that he or she may not leave the hospital Threatening to give a client a medication against his or her will Observing the provision of care to the client without the client’s permission7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 4/117 Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Question 4 1 / 1 pts A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? Ask the nursing assistant to complete an incident report Correct! Correct! Check the client s level of consciousness and vital signs Ask the nursing assistant to assist in getting the client back to bed Contact the unit secretary on the intercom and ask that the client’s health care provider be called7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 5/117 Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review client injuries and procedures for filing incident reports if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 5 1 / 1 pts Which action exemplifies the use of evidence-based practice in the delivery of client care? Donning sterile gloves to change an abdominal wound dressing Correct! Correct! Encouraging a client to take an herbal substance to treat his insomnia Advising a client to agree to the treatment recommended by her health care provider7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 6/117 Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidencebased practice because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review the situations that reflect evidence-based practice if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 6 1 / 1 pts The nurse is working with the registered nurse who has accepted a new position as case manager in a hospital. The nurse realizes which responsibilities are part of the registered nurse’s new role? Select all that apply. Correct! Correct! Evaluating and updating the plan of care as needed Prescribing treatments specific to the client s needs7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 7/117 Assessing the client s needs for home supplies and equipment Correct! Correct! Correct! Correct! Coordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client Correct! Correct! Rationale: A case manager is a nurse who assumes responsibility for coordinating the client’s care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the responsibilities of the case manager if you have difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 7 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 8/117 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 9/117 Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “lookingback,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 8 1 / 1 pts A nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? Ask the client whether the necklace is gold.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 10/117 Ask the client for permission to lock the necklace in the hospital safe. Correct! Correct! Ask the client to remove the necklace and place it in the top drawer of the bedside table. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure. Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test-Taking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review the procedures for safeguarding a client’s valuables if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 9 1 / 1 pts A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 11/117 that the client is wearing a wedding band on her left ring finger. The nurse should take which action? Tape the wedding band in place. Correct! Correct! Explain to the client why the wedding band must be removed. Ask the client whether she would like to remove the wedding band or wear it to surgery. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery. Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a health care facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the comparable or alike options that indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review preoperative procedures for a client’s valuables if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 12/117 Question 10 1 / 1 pts A nurse preparing a client to go to the radiology department for a neck x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? Asking the client to remove the medal until the x-ray has been completed Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct! Correct! Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the x-ray7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 13/117 Rationale: A client undergoing a neck x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost. Test-Taking Strategy: Use the process of elimination and note that the client is expressing concern about removing the religious medal. Eliminate the comparable or alike options that indicate that the client should remove the medal. Also note that the correct option is the only option that addresses the client’s concern. Review care of clients’ valuables if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 11 1 / 1 pts A health care provider writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take? Correct! Correct! Contacting the nursing supervisor Continuing to transcribe the prescription7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 14/117 Asking the nurse assigned to care for the client to administer the medication Verifying the prescribed dose with the client before administering the medication Rationale: A nurse must follow a health care provider’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the health care provider is necessary. If the health care provider confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the medication would be administered. Review the nurse’s responsibilities in regard to a health care provider’s prescriptions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 12 1 / 1 pts nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 15/117 Call the nursing supervisor. Explain the procedure to the client, then remove the chest tube. Inform the health care provider that removal of a chest tube is not a nursing procedure. Correct! Correct! Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube. Rationale: Actual removal of a chest tube is the duty of a health care provider. Therefore the nurse would first inform the health care provider that this is not a nursing procedure. If the health care provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies’ policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word “first.” The nurse should discuss the prescription with the health care provider. Review nursing responsibilities with regard to removal of a chest tube and standards of care if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 13 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 16/117 A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? Calling the health care provider who gave the telephone prescription to clarify the prescription Correct! Correct! Calling the nursing supervisor for assistance in determining the route of administration Administering the medication intravenously because this route is generally used for clients with CHF Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 17/117 Rationale: Telephone prescriptions involve a health care provider’s dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider’s prescription sheet or enters it into the electronic medical record. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the health care provider who gave the telephone prescription and clarify the prescription. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the nurse should administer the medication without clarifying the health care provider’s prescription. Review the procedures for accepting telephone prescriptions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 14 1 / 1 pts A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation? Calling the nursing supervisor to obtain permission to accept the verbal prescription Changing the solution and rate of the IV fluid per the health care provider’s verbal prescription7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 18/117 Asking the health care provider to write the prescription in the client’s record before leaving the nursing unit Correct! Correct! Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record Rationale: The health care provider should write all prescriptions. Verbal prescriptions are not recommended because they increase the risk for error. If a verbal prescription is necessary, such as during an emergency, it should be written and signed by the health care provider as soon as possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding verbal prescriptions. The appropriate nursing action would be to ask the health care provider to write the prescription in the client’s record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record delays necessary treatment. Test-Taking Strategy: Use the process of elimination and note the strategic words “most appropriate.” Eliminate the comparable or alike options that imply acceptance of the verbal prescription by the nurse. To select from the remaining options, recall the guidelines and principles for implementing health care provider prescriptions. This will direct you to the correct option. Review nursing responsibilities related to verbal prescriptions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 15 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 19/117 A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by undertaking which action? Reassuring the client that the risks are minimal Calling the surgeon and asking that the risks be explained to the client Correct! Correct! Noting in the client’s record that the client was not told about the risks of the surgery Writing a note on the front of the client’s record so that the surgeon will see it when the client arrives in the operating room Rationale: A nurse serves as a client advocate by protecting the right of the client to be informed and to participate in decisions regarding care. The only option that ensures that the client will be informed of the risks of the surgery is contacting the surgeon and asking that the risks be explained to the client. Telling the client that the risks are minimal is false reassurance. Putting a note on the client’s chart or documenting that the client was not informed about the risks does ensure that the client will be informed. Test-Taking Strategy: Use the process of elimination and guidelines and principles of obtaining informed consent. Focusing on the data in the question, the words “never told about the risks of the surgery,” will direct you to the correct option, the only option that ensures that the client will be told about the risks. Review the role of a nurse as a client advocate if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 20/117 Question 16 1 / 1 pts A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which statement accurately describes the nurse’s response to the client? The nurse could be charged with battery. Correct! Correct! The nurse could be charged with assault. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the health care provider.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 21/117 Rationale: Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client’s consent, the nurse may be charged with assault. Therefore the nurse is not justified in administering the medication. Battery is any intentional touching without the client’s consent. Test-Taking Strategy: Focus on the data in the question and the nurse’s statement. Note that the nurse threatens the client. Next, recall the definition of assault, which will direct you to the correct option. Review violations of client rights if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 17 1 / 1 pts A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take? Contact the client’s health care provider. Correct! Correct! Report the incident to the nursing supervisor. Tell the client that the nurse did the right thing in giving the enema. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 22/117 Rationale: Battery is any intentional touching of a client without the client’s consent. Such contact may be harmful to the client, or it may merely be offensive to the client’s dignity. If a nurse discovers that battery of a client has occurred, the nurse should report the situation to the nursing supervisor. Telling the client that the nurse did the right thing in giving the enema is incorrect because the other nurse has violated the client’s rights. Confronting the nurse and telling her that she is going to be charged with battery would likely result in unnecessary conflict. Although the health care provider may need to be notified, the nurse should first report the situation to the nursing supervisor. Test-Taking Strategy: Use the process of elimination, and note the strategic words “most appropriate.” Next, focus on the subject, client rights. Recalling that any situation that constitutes a violation of a client’s rights needs to be reported and remembering the organizational channels of reporting will direct you to the correct option. Review the issues surrounding violation of client rights and nursing responsibilities when a client’s rights have been violated if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 18 1 / 1 pts A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes? The health care provider was called to clarify the prescription for morphine sulfate. Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 23/117 The health care provider made an error in the written prescription for morphine sulfate. The health care provider was called to correct an error in the dosage of morphine sulfate. An incorrect dosage of morphine sulfate was prescribed and the health care provider was notified. Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made an error or performed an incorrect action or procedure. If a health care provider’s prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the health care provider made an error in writing a prescription. These options contain the words “error” or “incorrect.” Review the principles of documentation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 19 1 / 1 pts A nurse at the long-term care unit on the 11 p.m. to 7 a.m. shift is gathering the nursing staff together to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which action is most appropriate for the nurse to take?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 24/117 Correct! Correct! Contact the nursing supervisor. Ask the staff member how much alcohol she has consumed. Tell the staff member that she is not allowed to administer medications. Ask the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 25/117 Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated nurse is removed from the situation. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident. Refusal to sign and date the memo should be noted by the nurse and a witness. Neither asking the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing client safety. Asking the staff member how much alcohol she has consumed is confrontational and irrelevant. Test-Taking Strategy: Use the process of elimination, keeping in mind that client safety is the priority. Asking the staff member how much alcohol she has consumed is irrelevant, so eliminate this option. Next eliminate the comparable or alike options that do not involve removal of the staff member from the client care area. Review nursing responsibilities when substance abuse is suspected in a staff member if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 20 1 / 1 pts A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information? That anatomic gifts must be made in writing and signed by the client Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 26/117 To speak with the chaplain about the psychosocial aspects of becoming a donor That this decision must be made by the next of kin at the time of the client’s death To let the health care provider know about the request so that it may be documented in the client’s record Rationale: An individual who is at least 18 years old may make an anatomic gift of all or part of the human body. The gift must be made in writing and signed by the donor. If the client cannot sign, the document must be signed by another individual and two witnesses. The health care provider is informed of the client’s wishes, and the client may wish to speak to a chaplain, but the specific procedure requires a written document that is signed by the client. The family of a deceased client may be asked about organ donation, but this is not the procedure when a living person wishes to become a donor. Test-Taking Strategy: Use the process of elimination, and focus on the subject, a client requesting information about organ donation. Eliminate the option using the closedended word “must.” To select from the remaining options, remember that an anatomic gift must be made in writing and signed by the client. Review the procedure for organ donation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 21 1 / 1 pts A nurse enters a client’s room to administer a medication that has been prescribed by the health care provider. The client asks the7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 27/117 nurse about the medication. Which response by the nurse is appropriate? “It’s to help get rid of the swelling in your feet.” “You need to discuss this medication with your health care provider.” “I know that it’s for fluid buildup, and I think you’ve taken it before.” “It’s called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we’ll need to increase the potassium in your diet.” Correct! Correct! Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Therefore the appropriate response is the one that is thorough and complete. Referring the client to the health care provider places the client’s question on hold. The remaining options are incomplete. Test-Taking Strategy: Note the strategic word “appropriate.” Eliminate the option that refers the client to the health care provider because it places the client’s question on hold. To select from the remaining choices, find the option that is most complete and thorough. Review client rights in regard to the provision of information about medication if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 28/117 Question 22 1 / 1 pts A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse. Which action by the nurse is appropriate? Correct! Correct! Telling the nursing student to allow the client to rest Telling the nursing student to give the client the bath anyway Telling the client that the health care provider will be informed of the refusal of care Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client’s decision. Therefore the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate and represent violations of the client’s rights. Telling the client that the health care provider will be informed of the refusal of care is a threatening action on the nurse’s part. Test-Taking Strategy: Use knowledge of the subject, client rights. Eliminate the options that present a threat to the client or indicate that the bath will be given regardless of the client’s wishes. Review client rights if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 29/117 Question 23 1 / 1 pts A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A bone scan is being performed. Correct! Correct! She will have to discuss the prescribed test with the client. The radiology department is not clear as to which test has been prescribed. She can read the client’s medical record to determine what the health care provider prescribed. Rationale: Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the appropriate response is to tell the client’s wife that she will have to discuss the test with the client. Likewise, a client’s medical record is confidential and cannot be given to the wife for reading. Telling the client’s wife that the radiology department is unclear as to what test has been prescribed is inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on another department. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, confidentiality, and recalling the issues surrounding confidentiality will direct you to the correct option. Review the issues surrounding confidentiality if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 30/117 Question 24 1 / 1 pts A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should take which action? Allow the television crew to videotape the program. Correct! Correct! Explain to the television crew that videotaping is not allowed. Ask the television crew to interview the individuals attending the program individually. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization. Rationale: Privacy is a client’s right to be free from unwanted intrusion into his or her private affairs. Videotaping constitutes an invasion of a client’s privacy, and written permission is required from the client for an action such as photographing or videotaping. Therefore the nurse must explain to the television crew that videotaping is not allowed. The other options are incorrect and constitute invasions of client privacy. Test-Taking Strategy: Focus on the subject, client privacy. Eliminate the comparable or alike options that represent invasions of client privacy. Review violations of client privacy if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 31/117 Question 25 1 / 1 pts A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? “Oh, really? I didn’t see that!” Correct! Correct! “We can’t discuss a client’s medical condition.” “Yes, that’s why we’ve imposed contact precautions.” “Yes, he does, but be sure not to discuss this with anyone else.” Rationale: A client’s medical condition is confidential and should never be discussed with anyone other than the client and the client’s health care provider. Therefore the nurse must tell the unit secretary that the client’s condition is not to be discussed. The statements “Yes, he does, but be sure not to discuss this with anyone else” and “Yes, that’s why we’ve imposed contact precautions” both confirm the client’s disease and are therefore inappropriate. Responding, “Oh, really? I didn’t see that!” promotes further discussion of the client’s condition and is inappropriate. Test-Taking Strategy: Use the process of elimination, and recall the issues surrounding confidentiality. This will help you eliminate the option that promotes further discussion of the client’s condition. Next, eliminate the comparable or alike options that confirm the client’s illness. Review the issues surrounding confidentiality if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 32/117 Question 26 1 / 1 pts A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action? Call the client’s health care provider. Contact the nursing supervisor for directions. Correct! Correct! Administer cardiopulmonary resuscitation (CPR). Administer oxygen to the client and call the health care provider. Rationale: CPR is an emergency treatment that is provided without client consent unless a DNR order is part of the client’s record. Calling the nursing supervisor for directions, administering oxygen to the client, and calling the health care provider are all inappropriate actions that would delay necessary treatment. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that delay necessary treatment. Review procedures related to CPR and DNR orders if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 27 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 33/117 A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse respond? Telling the health care provider that “slow codes” are not acceptable Correct! Correct! Telling the health care provider that the client would probably want to die in peace Telling the health care provider that all of the nurses on the unit agree with this plan Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 34/117 Rationale: The nurse may not violate a family’s request regarding the client’s treatment plan. A “slow code” is not acceptable, and the nurse should state this to the health care provider. The definition of a “slow code” varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are therefore inappropriate. Test-Taking Strategy: Focus on the data in the question— specifically, that the spouse will not grant permission for a DNR order. Recalling the procedures for CPR and the ethical/legal guidelines for a DNR order will direct you to the correct option. Review the nurse’s responsibility regarding DNR orders and standards of care if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 28 1 / 1 pts A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-notresuscitate (DNR) order. The nurse should provide the client with which information? Consent must be obtained from the family. The health care provider makes the final decision about a DNR request.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 35/117 The DNR request should be discussed with the health care provider, who will write the order. Correct! Correct! Oral consent is sufficient, and the client’s request will be honored by all health care providers. Rationale: A client may request a DNR order after being given the appropriate information by the health care provider. Therefore, if a client requests a DNR order, the nurse should contact the health care provider so that the health care provider may discuss the request with the client. A DNR order should be written, not verbal. The pertinent agency and state guidelines must be followed with regard to when a verbal DNR order is acceptable. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, issues related to DNR orders. Eliminate the options that contain the closedended words “must” and “all.” Next, recall that the client has the right to request a DNR order, which will direct you to the correct option from those remaining. Review the issues related to DNR orders if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 29 1 / 1 pts A man who is visiting his wife in a long-term care facility for people with Alzheimer disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 36/117 regarding do-not-resuscitate (DNR) orders does the nurse remember? That a DNR order may be written by a client’s health care provider Correct! Correct! That everything possible must be done if the client stops breathing That medications only may be given to the client if the client stops breathing That life support measures will have to be implemented if the client stops breathing Rationale: In a situation in which a client has no family members who can provide permission for treatment, the health care provider may write a DNR order if he or she is reasonably and medically certain that resuscitation would be futile. Therefore the other options are inaccurate. Test-Taking Strategy: Focus on the data in the question, and note that the client is terminally ill and has no family members other than a wife who is mentally incompetent. Eliminate the comparable or alike options that indicate that resuscitation measures will be instituted. Next eliminate the option containing the closed-ended word “only.” Review the ethical and legal issues related to DNR orders if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Question 30 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 37/117 A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands which information about DNR orders? The DNR order may not be changed once it is in effect The DNR order requires frequent review as specified by state or agency policy Correct! Correct! The only people who may change the DNR order are members of the client s immediate family The DNR order, as written on admission, must remain in effect for the duration of the client s hospitalization Rationale: If the client’s condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client’s hospitalization. The client’s request regarding DNR status is the priority. Test-Taking Strategy: Use the process of elimination. Eliminate the options that use the closed-ended words “may not” and “only.” To select from the remaining options, recall that a DNR status may be changed at any time. Review the ethical and legal issues regarding DNR orders if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Question 31 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 38/117 A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant? Suctioning a client who requires periodic suctioning Performing colostomy irrigation on a client with an ostomy Assisting a client who needs frequent ambulation with a walker Correct! Correct! Assessing a client who has undergone an arteriogram and requires close monitoring7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 39/117 Rationale: When a nurse assigns tasks of a client’s care to another staff member, the nurse is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed nurse because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to a licensed nurse because these personnel have the knowledge and education to detect changes in the client’s status that require attention. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment to a nursing assistant. Eliminate the comparable or alike options that involve invasive procedures. To select from the remaining options, think about the education that a nursing assistant receives. The nursing assistant is trained to ambulate a client with an assistive device but does not have the knowledge and education to detect changes in a client’s status. Review the guidelines for assignment of tasks if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 32 1 / 1 pts A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN? Feeding a client on bedrest who needs assistance with feeding7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 40/117 Turning a client who must be turned and repositioned every 2 hours Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments Correct! Correct! Assisting a client who is wearing eye patches and requires assistance with hygiene measures Rationale: When a nurse assigns tasks for a client’s care to another staff member, the nurse is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client’s condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment of tasks to an LPN. Think about the activities that the LPN is able to perform. Next, eliminate the comparable or alike options that are noninvasive procedures. Review the principles of assigning tasks if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 33 0.5 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 41/117 nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply. Correct! Correct! Conducting client rounds before taking the break Taking the break in the staff lounge located on the nursing unit Correct Answer Correct Answer Asking the nursing assistant to administer a medication placed at the client s bedside if the client awakens Asking the nursing assistant to monitor a client s tube feeding and to contact the nurse when the feeding bag is empty Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby Question 34 1 / 1 pts A nurse is providing a change-of-shift report on the assigned clients using an audiotape. Which pieces of information should the nurse include in the report about each assigned client? Select all that apply. Family history Correct! Correct! Client needs and priorities of care Correct! Correct! Current diagnosis and any secondary diagnoses Correct! Correct! Results of laboratory studies conducted that day7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 42/117 Correct! Correct! Client response to treatments implemented that day The steps used to perform the procedure for changing the client’s sterile dressing at the gastrostomy tube site Rationale: A change-of-shift report ensures continuity of care among nurses caring for a client and informs the nurse on the next shift about the client's needs and priorities for care. It may be given written, orally, by audiotape or while the nurses are walking rounds at a client’s bedside. The report should describe the client’s health status, current and secondary diagnoses, results of laboratory or diagnostic studies done that day, and the client’s response to treatments implemented that day. The client’s family history does not need to be described in a change-of shift report, and doing so would take time. If such information is needed by the oncoming nurse, it may be obtained from the client’s medical record. There is no useful reason for describing a routine procedure; this would also take time, and the information is available in the agency procedure manual. Test-Taking Strategy: Focus on the subject, what to include in the change-of-shift report. Read each option carefully and eliminate family history because it is not directly related to the client’s current status. Next eliminate the option that involves describing the steps in performing a procedure because this is routine information. Also note that the correct options are client focused. Review the components of a change-of-shift report if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Question 35 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 43/117 A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first? Correct! Correct! A client scheduled for hemodialysis at 10 a.m. A client scheduled for a nuclear scanning procedure at 10 a.m. A client scheduled for contrast computed tomography (CT) at noon A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 a.m.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 44/117 Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client’s weight and lung sounds. The nurse must also assess the client’s predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 a.m. may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 a.m. may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory, and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload. Review the principles of prioritizing if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 36 1 / 1 pts A nurse has assigned several nursing tasks to staff members. Which is the nurse’s primary responsibility after assigning tasks? Documenting completion of each task7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 45/117 Assigning any tasks that were not completed to the next nursing shift Allowing each staff member to make judgments when performing the tasks Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Correct! Correct! Rationale: The ultimate responsibility for a task lies with the person who assigned it. Therefore it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Not all staff members have the education, knowledge, and ability to make judgments about the tasks being performed. The nurse would document that the task was completed, but this would not be done until follow-up had been conducted and outcomes identified. It is not appropriate to assign the tasks that have not been completed to the next nursing shift; this action does not ensure that client needs will be met and also increases the workload for the next shift. Test-Taking Strategy: Use the process of elimination, noting the strategic words “primary responsibility.” Recalling that the ultimate responsibility for a task lies with the person who delegated it will direct you to the correct option. Review the guidelines for delegation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 37 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 46/117 A case manager is reviewing progress notes in a client’s medical record. Which notation indicates the need for follow-up? S. No Client Condition Notation 1. Client 1 Status postmastectomy: 18 hours Five milliliters of bloody drainage was emptied from the JacksonPratt drain. 2. Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation. 3. Client 3 Status postappendectomy: 24 hours The surgical dressing is clean and dry. 4. Client 4 Diabetes mellitus Blood glucose level is 124 mg/dL. 1 2 Correct! Correct! 3 47/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 47/117 Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care, evaluating and updating the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. Crackles heard in the lower lobes of the lungs in a client with heart failure are an unexpected and unwanted outcome requiring follow-up because they could indicate the development of pulmonary edema. The notations made for the other clients listed represent expected outcomes. Test-Taking Strategy: Think about the role of the case manager and read each notation carefully. Next, focus on the subject, the need for follow-up. This will direct you to the notation that represents an unexpected or unwanted outcome. Crackles heard in the lower lobes of the lungs on auscultation are a matter of concern. Review the role of the case manager and the expected and unexpected findings for the client conditions noted in the options if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 38 0 / 1 pts The nurse reviewing a client’s record for the 7 a.m. to 7 p.m. work shift sees that the following medications are prescribed. Which medication should the nurse plan to administer first? Client Medications 1. Atorvastatin 10 mg orally 2. Zolpidem 5 mg orally daily7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 48/117 3. Ferrous sulfate 1 tablet orally 4. Levothyroxine 137 mg orally Y You Answered ou Answered 1 2 3 4 Correct Answer Correct Answer Rationale: For adequate absorption, levothyroxine must be administered with water on an empty stomach as soon as the client awakens and at least 1 hour apart from other fluids (e.g., coffee or tea), food, and other medications. Therefore this medication should be administered first. Atorvastatin (Lipitor), an HMG-CoA reductase inhibitor used to lower cholesterol, is administered at bedtime because cholesterol synthesis is increased during the night. Zolpidem, a benzodiazepine-like medication used to enhance sleep, is administered at bedtime. Ferrous sulfate is an iron supplement that is administered with water between meals. Test-Taking Strategy: Note the strategic word “first.” Think about the classification of each medication to determine its action. This will help you answer correctly. Also note that atorvastatin and zolpidem are comparable or alike in that they are administered at bedtime. Next, recalling the action of levothyroxine will direct you to this option. Review the medications in the options and their method of administration if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 39 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 49/117 A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict? Ignoring the resistance Telling the CNA that noncompliance will be documented in the personnel record Meeting with the CNA and encouraging him to express his feelings regarding the change Correct! Correct! Telling the CNA that a licensed practical nurse (LPN) will perform all of the computer documentation if he will document all intake and output and vital signs7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 50/117 Rationale: Face-to-face meetings to confront the issue at hand allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Ignoring the resistance does not address the problem. Providing a temporary solution to the resistance by having the LPN do all of the computer work and having the CNA perform only specific documentation will not specifically address the concern. Telling the CNA that the noncompliance will be documented in his personnel record may produce additional resistance. Test-Taking Strategy: Focus on the subject, the best approach to dealing with a conflict. Use the process of elimination and eliminate the options that are comparable or alike in that they represent direct avoidance of the conflict. If you had difficulty with this question, review the best approaches to with dealing with conflict. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 40 1 / 1 pts A licensed practical nurse (LPN) is planning client assignments for the day. Which tasks should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. Changing the dressing of a client with a permanent tracheostomy Changing the gastrostomy tube dressing on a client Transporting a client to the radiology department in a wheelchair Correct! Correct! Recording the urine output for a client with a Foley catheter for whom a 24-hour urine collection is in progress Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 51/117 Listening to bowel sounds for a client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter Rationale: The nurse must base assignments on the basis of the skills of the staff member and the needs of the client. The nursing assistant is capable of recording the urine output for the client with a Foley catheter for whom a 24-hour urine collection is in progress and transporting a client to the radiology department in a wheelchair. The nursing assistant is skilled in such tasks. The client who has just undergone surgery will require specific monitoring in addition to recording of vital signs. Dressing changes and tracheostomy care are not performed by unlicensed personnel. Test-Taking Strategy: Focus on the subject, assignments for the nursing assistant. Think about the skills that the nursing assistant can perform and remember that the nursing assistant may perform tasks that are noninvasive. Review the principles of delegation and assignmentmaking if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 41 1 / 1 pts A licensed practical nurse (LPN) is planning task assignments for five clients on the skilled nursing unit in a long-term care facility. The team includes another licensed practical nurse (LPN) and a nursing assistant. Which tasks should the nurse assign to the LPN? Select all that apply. Bathing a client who is confused and requires assistance with a shower7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 52/117 Assisting a client requiring a bed bath and frequent ambulation with a cane Transporting a client who must be accompanied to physical therapy twice during the shift Providing teaching for a client with a colostomy who requires reinforcement regarding the procedure for irrigation Correct! Correct! Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus Correct! Correct! Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned the tasks of caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to reinforce teaching regarding the colostomy irrigation (the RN is responsible for the initial teaching) and administering regular insulin in accordance with a sliding scale. Test-Taking Strategy: Focus on the subject, the client assignment for the LPN. Use the process of elimination to eliminate the clients whose needs are noninvasive because a nursing assistant may perform these tasks. This will help you identify the clients who may be assigned to the LPN. If you had difficulty with this question, review the principles of delegation and assignment-making. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 42 0 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 53/117 A nurse has received the assignment for the day shift. Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared to first? Correct Answer Correct Answer A client who is scheduled for surgery at 1 p.m. A client scheduled for physical therapy at 11 a.m. A client in skeletal traction who has just received pain medication A client who is able to perform activities of daily living independently Y You Answered ou Answered Rationale: For the client assignment presented, the nurse would plan to care for the client who is scheduled for surgery at 1 p.m. first. Several items need to be addressed before surgery, including client preparation (physical and emotional) and health care provider prescriptions, all of which will take time. Also, many times the operating room will make late changes in the schedule, depending on room and health care provider availability, and will request an earlier surgical time. Therefore it is best to ensure that this client is prepared. It is best to wait for pain medication to take effect before providing care to a client. The needs of the client who is independent and the client scheduled for physical therapy later in the morning are not high priorities. Test-Taking Strategy: Use the process of elimination and principles related to prioritization. Focus on the subject, the client for whom the nurse will care first. Noting that an assigned client is scheduled for surgery and recalling the many needs of a client about to undergo surgery will direct you to the correct option. Review the principles of prioritizing if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 54/117 Question 43 1 / 1 pts A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow-up? Select all that apply. A client is performing his own colostomy irrigations. A client with a central venous catheter has a temperature of 100.6°F. Correct! Correct! A client with a new diagnosis of diabetes mellitus is selfadministering insulin. A client who has just undergone surgery has a urine output of more than 30 mL/hr. A client who has just undergone surgery is getting relief from the prescribed pain medication.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 55/117 Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. A temperature of 100.6°F in a client with a central venous catheter is an unexpected and unwanted outcome, requiring the need for follow-up because it may indicate the development of an infection. The other options all represent expected outcomes. Test-Taking Strategy: Think about the role of the case manager, and read each client description carefully. Next, focus on the subject, an unexpected outcome and the need for follow-up. This will direct you to the outcome that is unexpected or unwanted. An increased temperature is a concern because it is a sign of infection. Review the role of the case manager and information on these expected and unexpected outcomes if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 44 1 / 1 pts A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, which is the first activity that the nurse would suggest to the task force? Teaching schoolchildren about the dangers of school violence7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 56/117 Looking at what other communities are doing about school violence Distributing fliers that identify the causes of school violence to families in the community Conducting a community survey to assess community perceptions regarding school violence Correct! Correct! Rationale: An assessment activity is always the first step in the nursing process. Conducting a community survey on school violence addresses assessment of community perceptions. Teaching schoolchildren about the dangers of violence and distributing fliers that identify the cause of school violence are implementation measures. Looking at what other communities are doing is part of the analysis of a variety of assessment data but is not specific to the subject of the question. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Eliminate the options that are implementation actions. To select from the remaining options, note the word “assess” in the correct option. Review the various roles of the nurse and the process of assessment if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 45 1 / 1 pts A nurse planning care for her assigned clients understands that which aspect is the purpose of the hospital’s standards of care?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 57/117 Identify methods of treatment. Correct! Correct! Provide direction for the practice of nursing. Provide direction for care on the basis of the client’s diagnosis. Identify new care methods on the basis of current medical research. Rationale: The purpose of standards of care is to provide a broad direction for the overall practice of nursing that applies to all nursing situations, across specialty areas, across the country. Standards of care include the provision of competent care on the basis of current practice. Methods of treatment are individualized to the care of a specific client. Providing direction of care on the basis of the client’s diagnosis is a matter of medical interventions. New care methods are a matter of research. Test-Taking Strategy: Focus on the subject, standards of care. Note the relationship of the subject and the information in the correct option. The correct option is also the umbrella option. Review the purpose of standards of care if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 46 1 / 1 pts A nurse is supervising a nursing assistant ambulating a client with right-sided weakness. The nurse would conclude that the nursing assistant is performing the procedure incorrectly after observing the nursing assistant taking which action?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 58/117 Correct! Correct! Stands behind the client Stands on the right side of the client Positions the free hand on the client s shoulder Grasps the security belt in the midspine area of the small of the client s back Rationale: When walking with a client, the nurse should stand on the affected side and grasp the security belt in the midspine area of the small of the client’s back. The nurse should position the free hand at the shoulder area so that the client may be pulled toward the nurse in the event that there is a forward fall. Test-Taking Strategy: Note the strategic word “incorrectly.” This word indicates a negative event query and the need to select the unsafe action by the nursing assistant. Visualizing the action in each option will direct you to the unsafe and incorrect action. Review the procedure for assisting ambulation of a client with weakness if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 47 1 / 1 pts A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client’s deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique? Administers the injection in the thigh7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 59/117 Places the client in the Sims position Positions the client in a prone toe-in position Administers the injection 2 inches below the acromion process Correct! Correct! Rationale: The nurse may be responsible for supervising certain procedures performed by a new employee to ensure that client safety is maintained. The deltoid muscle is located in the upper arm area. Administration of an injection into this muscle is done 2 inches below the acromion process (the bony structure on top of the shoulder blade). Therefore the injection is not given in the thigh (vastus lateralis or rectus femoris muscle). The Sims position is not the correct position for an injection into the deltoid muscle. A prone toe-in position is used for injection into the dorsogluteal site or gluteus medius muscle because it will promote internal rotation of the hips, which relaxes the muscle and makes the injection less painful. Test-Taking Strategy: Note the strategic words “deltoid muscle.” Visualize each description in the options and use your knowledge of the anatomical locations of the various muscles to find the correct option. If you are unfamiliar with the administration of IM medications in the deltoid muscle, review the correct procedure. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 48 0 / 1 pts A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 60/117 “The care map is developed by a nurse and identifies nursing diagnoses.” “The care map is a plan that is used only by the nurse to provide client care.” “The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge.” Correct Answer Correct Answer “The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis.” Y You Answered ou Answered Rationale: The care map is a type of critical pathway that incorporates expected day-to-day client outcomes and those anticipated at discharge or at the end of a treatment phase. It outlines clinical assessments, treatments and procedures, dietary interventions, activity and exercise therapies, client education, and discharge planning. It may identify nursing diagnoses but is developed by members of all disciplines that normally care for the particular client type and is used by all members of the interdisciplinary team. Continuity of care can be achieved with the use of a care map. Test-Taking Strategy: Eliminate the comparable or alike options that refer to the care map as a nursing tool only. Also note that the correct option is the umbrella option. Review the purpose and use of the care map if you had difficulty with this question. Level of Cognitive Ability: Evaluation Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 49 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 61/117 The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant? Completing the preoperative checklist for a client scheduled for a liver biopsy Providing oral care to an unconscious client who requires oral care Correct! Correct! Monitoring for bleeding for a client who has just undergone cardiac catheterization Assisting a client who is getting up to ambulate for the first time after surgery7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 62/117 Rationale: The nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. Oral care may be assigned to a nursing assistant. The nurse would provide instructions to the nursing assistant regarding the task, how to adapt the procedure for the client at risk for aspiration, and the signs of complications that must be reported immediately (e.g., bleeding gums, excessive coughing). A client who has just undergone cardiac catheterization requires monitoring for complications, and a client scheduled for liver biopsy requires preparation for the test and client teaching. A client who is getting up to ambulate for the first time after surgery is at risk for orthostatic hypotension and should be assisted by a licensed nurse. Test-Taking Strategy: Note that the question asks for the assignment to be assigned to the nursing assistant. When asked questions related to delegation, think about the role description of the employee and the needs of the client. For the nursing assistant, select the client who has needs that do not require a high skill level, meaning that assessment, teaching, and monitoring are not appropriate. Note that two of the incorrect comparable or alike options that identify clients who have undergone invasive procedures. Review the guidelines related to delegation to a nursing assistant if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 50 1 / 1 pts A licensed practical nurse tells the certified nursing assistant (CNA) staff that they will need to comply with the mandatory overtime policy that the long-term care facility has implemented. Later that day, the nurse overhears a CNA complaining about the policy and telling other CNAs that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse to use in dealing with the conflict?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 63/117 Ignoring the complaints Avoiding assigning the CNA mandatory overtime Meeting with the CNA regarding her behavior regarding the overtime policy Correct! Correct! Providing a positive reward system for the CNA so that the CNA will agree to work the mandatory overtime Rationale: Initiating a discussion is an important strategy for addressing resistance by a staff member who is complaining about an agency protocol. Face-to-face meetings to discuss the issue at hand will allow verbalization of feelings and identification of problems and issues, and give the nurse manager the opportunity to develop strategies to solve the problem. Ignoring the complaints and avoiding assigning the nurse mandatory overtime are inappropriate strategies that do not address the problem. Providing a positive reward system might provide a temporary solution to the resistance but will not specifically address the problem. Test-Taking Strategy: Note the strategic word “best” in the query of the question, and focus on the subject, dealing with conflict. Eliminate the options that ignore the CNA’s complaints. To select from the remaining options, look for the option that specifically addresses the subject and provides problem-solving measures. If you had difficulty with this question, review the strategies associated with dealing with conflict. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 51 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 64/117 A nurse is planning client assignments for the day. Which task should the nurse assign to the nursing assistant (unlicensed assistive personnel)? Preprocedural teaching for a client scheduled for a cardiac stress test Dressing change instructions for client who had a mastectomy 2 days ago Reporting abnormal lab values the health care provider for a client scheduled for a laparoscopic cholecystectomy Recording the urinary output for a client with renal calculi whose urine must be strained Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 65/117 Rationale: The nurse is legally responsible for client assignments and must assign tasks on the basis of the guidelines of the state nursing practice act and the job descriptions set forth by the employing agency. The nursing assistant has been trained to measure, collect, and strain urine. The nurse would provide instructions to the nursing assistant regarding the task, but the task is within the role description of a nursing assistant. A client scheduled for a cardiac stress test requires preprocedure preparation for the test, which is not a task within the role description for a nursing assistant. The nursing assistant cannot provide dressing change instructions to a client who has had a mastectomy. It is not within the role description of the nursing assistant to report abnormal laboratory values to the health care provider. Test-Taking Strategy: Note that the question asks for the tasks to be assigned to the nursing assistant. When asked questions related to delegation, think about the role description of the employee and the needs of the client. Eliminate the comparable or alike options that are invasive and require higher level of skill. For the nursing assistant, select the tasks that are noninvasive and do not require a high skill level, meaning that assessment, teaching, and monitoring are inappropriate tasks. Review the guidelines related to delegation to a nursing assistant if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 52 1 / 1 pts The registered nurse (RN) has made client assignments for the licensed practical nurse (LPN). Which assignment should the LPN question as being beyond the scope of the LPN? The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy. Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 66/117 The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man. The LPN is assigned to care for a client with diabetes mellitus who will need to have instructions reinforced on how to selfadminister insulin. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications. Rationale: To determine what may and may not be delegated to the various co-workers, the RN making the assignment must take into account several factors: the level of care required by each client, both immediately and in the future; the competencies possessed by the coworkers; and the legal limitations on the practice of those coworkers. The LPN should be able to recognize when an assignment is beyond the scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Reinforcing teaching on self-administration of insulin and discharge instructions on dressing changes is within the scope of an LPN. It is also within the scope of practice for the LPN to assist with discharge for a client who is going home with no new medications. Test-Taking Strategy: Use the process of elimination, noting the strategic word “question.” Eliminate the options in which the LPN is assigned to a client requiring chemotherapy. To select from the remaining options, focus on each client and think about his or her actual and potential needs. The RN is best assigned to the client who will be receiving chemotherapy. Review the guidelines for delegation and assignment-making if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 67/117 Question 53 1 / 1 pts A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? Home care Social services Physical therapy Correct! Correct! Occupational therapy Rationale: An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding himself or herself with the use of an adaptive device. Home care provides a variety of support services for the client and family, but the specific assistance needed for this client would be provided by the occupational therapist. A social worker is educated to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. Test-Taking Strategy: Use the process of elimination and focus on the subject, the need for assistance in eating. Recalling the functions and roles of the occupational therapist and the other health care workers in the options will help you answer correctly. Review the roles of the various health care team members if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 68/117 Question 54 1 / 1 pts A case manager is reviewing notations made in clients’ records. Which note indicates an unexpected outcome and the need for immediate follow-up? A client who has sustained a stroke dresses herself. A client exhibits signs of increased intracranial pressure after a craniotomy. Correct! Correct! Normal neurological findings are noted in a client with a cerebral aneurysm. A client with a spinal cord injury transfers himself from a bed to a wheelchair.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 69/117 Rationale: A case manager is a nurse who assumes responsibility for coordinating a client’s care from the point of admission through, and after, discharge. This nurse initiates a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluates and updates the plan of care as needed. The case manager monitors the client for expected and unexpected outcomes and provides follow-up and revises the plan of care if an unexpected outcome is noted. A client who exhibits signs of increased intracranial pressure after a craniotomy, indicating a deterioration of the client’s condition, requires immediate follow-up. The descriptions in the other options are expected outcomes.. Test-Taking Strategy: Think about the role of the case manager, and read each client description carefully. Next, focus on the subject, an unexpected outcome and the need for immediate follow-up. This will direct you to the description that is unexpected or unwanted. Signs of increased intracranial pressure are an immediate concern, indicating deterioration in the client’s condition. Review the role of the case manager and expected and unexpected outcomes if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Leadership/Management Question 55 1 / 1 pts A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which services does the nurse suggest a referral? Correct! Correct! Home care Social services Physical therapy7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 70/117 Occupational therapy Rationale: Home care provides a variety of support services for the client and family, including assistance with the administration of insulin. For the client who has difficulty drawing insulin into a syringe, the home care nurse would prefill a week’s supply of syringes containing the required dose. These syringes would be placed in the client’s refrigerator for self-administration by the client. A social worker is educated to counsel clients in a variety of areas and may assist with the financial aspects of care. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding himself or herself with the use of an adaptive device. Test-Taking Strategy: Use the process of elimination and focus on the subject, the need for assistance with insulin administration. Recalling the functions and roles of the home care nurse and the health care workers in the other options will help you answer correctly. Review the roles of various health care team members if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 56 1 / 1 pts A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant? Correct! Correct! Assisting a client with dysphagia in eating Providing hygiene to a client with dementia7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 71/117 Ambulating a client with Parkinson disease Assisting a client with an above-the-knee amputation in showering Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting a client with dysphagia with eating because of the risk of complications such as choking and aspiration. The remaining three situations include no data to indicate that these tasks carry any unforeseen risk. Test-Taking Strategy: Note the strategic words “least appropriate.” Use the ABCs—airway, breathing, and circulation—and recall the principles of delegation and supervision of tasks in answering the question. Remember, delegation of work must be consistent with the individual’s level of expertise and licensure or lack of licensure. Review the principles of assignments and delegation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 57 1 / 1 pts A nurse is assigned to care for four clients. Which client should the nurse assess first? A client scheduled for a colonoscopy A client preparing for discharge after surgery A client requiring a tube feeding through a gastrostomy tube7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 72/117 A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask Correct! Correct! Rationale: Airway is always the priority, so the nurse would attend to the client who has a condition related to airway first. The other clients do not have conditions related to the airway and represent intermediate priorities. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. The client with a tracheostomy is the only client with an airway problem. Remember that airway is always the first priority. Review the guidelines for prioritization if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 58 1 / 1 pts A nurse is planning the assignments for the shift. Which task should the nurse assign to the nursing assistant? Monitoring the vital signs for a client who needs a blood transfusion Performing hygiene for a client with diarrhea on whom contact precautions have been imposed Correct! Correct! Ambulating a client with angina who needs to be ambulated for the first time since admission7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 73/117 Performing a dressing change on a client with a draining abdominal wound that requires frequent dressing changes Rationale: Assignment of tasks must be based the job description of the nursing assistant, the assistant’s level of clinical competence, and state law. Blood transfusions, dressing changes, and ambulation of a client with angina require the skill of a licensed nurse. A client under contact precautions is the most appropriate assignment for the nursing assistant because the nursing assistant is educated to provide hygiene care and to care for clients under specific precautions. Test-Taking Strategy: Use the process of elimination and knowledge of the subject, tasks that may be safely assigned to the nursing assistant. Read each client description, and think about the needs of the client. Recalling that clients requiring invasive procedures or close monitoring must be assigned to a licensed nurse will assist you in answering correctly. Review the principles of delegation and assignment-making if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 59 1 / 1 pts A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action? Allows time for unexpected tasks Prioritizes client needs and daily tasks7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 74/117 Gathers supplies before beginning a task Documents task completion and client information at the end of the day Correct! Correct! Rationale: The nurse should document task completion and client information throughout the day. Allowing time for unexpected tasks, prioritizing needs and tasks, and gathering supplies before beginning a task are all components of time management. Test-Taking Strategy: Note the strategic words “needs assistance.” These words indicate a negative event query and the need to select the incorrect action by the nursing graduate. Read each option carefully, and recall the guidelines for time management to answer the question. If you had difficulty with this question, review the principles of time management and documentation. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 60 1 / 1 pts A new nurse employed at a community hospital is reading the organization’s mission statement. The new nurse understands that this statement is written for which purpose? To describe the benefits available to employees Correct! Correct! To outline what the organization plans to accomplish To identify the policies and procedures of the organization7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 75/117 To define the rules of the organization that the employees must follow Rationale: All organizations have a purpose or reason for existing. This purpose is often expressed in the form of a mission statement. The mission statement outlines what the organization plans to accomplish. Sometimes mission statements incorporate statements of philosophy (beliefs), purpose, and goals or objectives into a single statement; other times the philosophy, purposes, and goals are addressed in addition to the mission statement. These statements serve as a benchmark against which an organization’s performance may be evaluated. The mission statement does not describe the benefits available to the employee; this is usually done by the human resources department. The rules of the organization are identified in policies and procedures, which are usually maintained in manuals kept in the nursing units or online. Test-Taking Strategy: Use the process of elimination, focusing on the subject, a mission statement. Note the relationship between the definition of a mission statement and the correct option. Review the description of an organization’s mission statement if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 61 1 / 1 pts A nurse, newly employed by a home health agency, is told that the organization’s decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in whom? Every employee7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 76/117 Correct! Correct! A few individuals, such as the board of directors All nursing employees, pharmacists, and hospital health care providers Many individuals, with decisions filtering down to the individual employee Rationale: Organizations may be described as having a centralized or decentralized structure in regard to the decision-making process. An organization is depicted as centralized when the authority to make decisions is vested in a few individuals. Conversely, when the decisionmaking involves a number of individuals, with decisions filtering down to the individual employee, the organization is said to operate in a decentralized fashion. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that several people associated with the organization make decisions. Review the differences between centralized and decentralized organizations if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 62 1 / 1 pts A nurse is employed in a community hospital as a staff nurse and is supervised by a nurse manager. The nurse understands that in this position, the term authority most appropriately refers to which description? Being responsible for what staff members do7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 77/117 Accepting the responsibility for the actions of others Carrying the legal responsibility for others’ performance of tasks The official power to see that an organizational decision is enforced Correct! Correct! Rationale: The term authority refers to the official power of an individual to approve or command an action or to see that a decision is enforced. Being responsible for what staff members do, accepting responsibility for the action of others, and carrying legal responsibility for others are not related to the description of a position of authority. Test-Taking Strategy: Use the process of elimination and knowledge regarding the subject, the description of a position of authority. Note the relationship between the word “authority” in the question and “power” in the correct option. Also note the incorrect comparable or alike options that involve responsibility. Review the description of authority if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 63 1 / 1 pts A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. “Accountability can be delegated.” Correct! Correct! “You are responsible for your own actions.”7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 78/117 Correct! Correct! “It carries legal implications for task performance.” “You must answer for the care that you ask others to complete.” Correct! Correct! “It refers to the process of answering or being responsible for what occurs.” Correct! Correct! Rationale: Accountability, the process of answering or being responsible for what occurs, carries legal implications for task performance. Accountability cannot be delegated; one is responsible for one’s own actions and must answer for the care given, as well as for the care one asks others to complete. Test-Taking Strategy: Focus on the subject, the definition of accountability. Recalling this definition will easily direct you to the correct options. Review the definition of accountability if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Question 64 1 / 1 pts A nurse is working in an urgent care center during the night shift. A client arrives at the center for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client’s injury, the nurse should take which action? Ask a medical assistant. Call the nurse in charge of the day shift. Ask the police officers who brought the client to the center.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 79/117 Check the unit policy for the protocol for the care of clients who have been sexually assaulted. Correct! Correct! Rationale: A policy or procedure is a designated plan or course of action to be taken in a specific situation. Written copies of all policies are usually placed in a policy manual that is available in each department or may be available online. Specific unit policies are sometimes referred to as protocols. The policy or protocol for a client who has been raped will describe the physical, psychosocial, and legal responsibilities of the nurse. Calling the nurse in charge during the day shift or asking an medical assistant or the police officers who brought the client into the center is inappropriate. If the nurse needs additional information after reviewing the policy or protocol, it would be most appropriate to contact the agency nursing supervisor of the night shift. Test-Taking Strategy: Use the process of elimination, recalling the legal implications related to providing care. Note the incorrect comparable or alike options that suggest obtaining information from other individuals. Review the purpose of organizational policies, procedures, or protocols if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 65 0.67 / 1 pts A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which options are accurate descriptions of these standards of care? Select all that apply. Are specific guidelines7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 80/117 Correct! Correct! Define professional practice Correct! Correct! Have some similarity to policies and procedures Are statements that relate only to the agency in which the nurse is employed Y You Answered ou Answered Are authoritative statements that describe a common or acceptable level of client care or performance Correct! Correct! Question 66 1 / 1 pts In which situation is the nurse upholding the ethical principle of fidelity? Allowing a client to decide when to receive daily hygiene care Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion Providing complete information regarding treatment options to a client with newly diagnosed cancer Contacting the health care provider about the client’s request to incorporate complementary therapies for pain into the treatment plan Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 81/117 Rationale: Fidelity is the keeping of promises made to clients, families, and other health care professionals. Contacting the health care provider about the client’s request that complementary therapies be used to relieve pain is an example of fidelity. Respect for a person’s autonomy, or independence, involves respecting that person’s right to determine his or her own course of action. Allowing a client to decide when he or she would like to have daily hygiene care is an example of respecting a client’s autonomy. Beneficence is taking action to help others. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion is an example of beneficence. Although insertion of an intravenous catheter might cause discomfort, the benefits of receiving the transfusion outweigh the temporary discomfort. Justice refers to fairness and equity; in the health care arena, this involves ensuring fair allocation of resources, such as nursing care, to all clients. Providing complete information regarding treatment options to each client with a cancer diagnosis is an example of justice. Test-Taking Strategy: Use the process of elimination and think about the subject, the definition of each item in the options. Note the relationship of the definition of fidelity and the correct option. Review the principles of health care ethics if you had difficulty with this question . Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 67 1 / 1 pts Which situation is an example of the use of evidence-based practice in the delivery of client care?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 82/117 Encouraging a client who has had a stroke to consume thin liquids and foods Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 83/117 Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into the sterile basin reflects evidence-based practice because this action cleans the lip of the bottle, thus preventing the entrance of harmful bacteria into the wound. The remaining options do not reflect evidencebased practice. Encouraging a client with a stroke to consume thin liquids and foods could cause harm because of the risk for choking; instead, such a client should receive thickened liquids. A dislodged radiation implant should be picked up with the use of long-handled forceps, not gloved hands, to be placed in a lead container to minimize radiation exposure. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab recontaminates the stick site. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note that the correct option prevents the entrance of harmful bacteria into the wound. Review the concept of evidence-based practice if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 68 1 / 1 pts A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client? Correct! Correct! Keeping the door to the client’s room closed Using a surgical mask when entering the client’s room7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 84/117 Placing the client in a semiprivate room with a cohort client Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Pulmonary tuberculosis is a respiratory infection that is transmitted to others by way of the airborne route. The door to the client’s room must be kept closed to prevent the transmission of the infection via the airborne route. The remaining options do not reflect evidence-based practice. An N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on entering the room. It is not necessary for the client to wear a mask. Airborne precautions require the use of a private room. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and recall that tuberculosis is transmitted by way of the airborne route. This will direct you to the correct option. Review the concept of evidence-based practice if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 69 1 / 1 pts A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 85/117 “I’m not working overtime today.” “You know how I hate to work overtime.” “I will if you need me, but I am not happy about this.” “I have plans after work and will not be able to work overtime.” Correct! Correct! Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse responds aggressively by stating, “I'm not working overtime today” or “You know how I hate to work overtime.” The statement “I will if you need me, but I am not happy about this” is a passive-aggressive response. Test-Taking Strategy: Use the process of elimination, focusing on the subject, the most assertive response. Note the relationship between the data in the question and the correct option. Review assertive communication techniques if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Question 70 1 / 1 pts A licensed practical nurse arrives at work at the long-term care center and is immediately faced with several activities that require attention. Which activity will the nurse attend to first? Stocking the medication closet Correct! Correct! Task assignments for the day7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 86/117 A phone message from a client’s wife A phone message from employee health services Rationale: The nurse must attend to task assignments first because client care is the priority. Also, the nursing staff need their assignments so that they may begin client care. The nurse should next check the medication supply to ensure that needed medications are available. The nurse would next return the phone calls. Test-Taking Strategy: Note the strategic word “first,” and use the process of elimination and prioritization skills. Remember that the client is the priority. Eliminate the options that are not directly related to immediate client needs. This will direct you to the correct option. Review the principles of prioritization and time management if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 71 0 / 1 pts A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant’s behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation? Ignoring the situation Asking other staff members to cover for the nursing assistant Documenting the problem in the nursing assistant’s personnel file Y You Answered ou Answered7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 87/117 Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures Correct Answer Correct Answer Rationale: Taking extended lunch breaks is an unacceptable behavior, mainly because the behavior affects client care. The nurse must meet with the nursing assistant to discuss the behavior and initiate problemsolving measures to ensure that the behavior does not continue. Ignoring the situation, asking other staff members to cover for the nursing assistant, and documenting the problem in the nursing assistant’s personnel file are all inappropriate because none of these actions will resolve the problem. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, the principles of dealing with conflict and unacceptable behavior. Remember that it is most appropriate to address a problem when it occurs. Also note that the comparable or alike options are incorrect in that they avoid the problem. Review the principles of dealing with conflict if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 72 1 / 1 pts A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients’ charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the health care provider, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? Fulfilling the health care provider’s request7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 88/117 Correct! Correct! Discussing the situation with the nurse manager Reporting the health care provider to the chief of medicine at the hospital Stating to the health care provider, “I don’t really care whether you report me. I am not writing your prescriptions.” Rationale: When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the health care provider’s request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the health care provider or seek assistance from the nursing supervisor. Fulfilling the health care provider’s request and writing the prescriptions in the clients’ charts ignores the issue. Reporting the health care provider to the chief of medicine is inappropriate because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating “I don’t care whether you report me. I am not writing your prescriptions” is an inappropriate statement and will result in further conflict between the nurse and health care provider. Test-Taking Strategy: Use your knowledge of the subject, conflict management, and the process of elimination. First eliminate the option that ignores the subject. Next eliminate the option that will result in further conflict between the nurse and health care provider. To select from the remaining options, think about the appropriate use of the organizational channels of communication; this will direct you to the correct option. Review the principles of managing conflict if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 89/117 Question 73 1 / 1 pts A nurse in a long-term care center notes that an employee is constantly calling in sick. Which action should the nurse take initially to handle this problem? Reporting the employee to administration Documenting the employee s behavior in the personnel file Telling the employee that she will be fired if she calls in sick again Reminding the employee of the employment standards of the agency Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 90/117 Rationale: When an employee demonstrates an unacceptable level of absenteeism, the nurse must first remind the employee of the employment standards of the agency. Sometimes an employee does not know or has forgotten the existing standards, and a reminder with no threats or discipline is all that is needed. When the oral reminder does not result in a change in behavior, the reminder should be placed in writing. If the written reminder fails, the employee should be granted a day of decision to determine whether to accept the standards for work attendance. Pay may be given for this day (depending on the agency protocol) so that it is not interpreted as punishment, and the employee must return to work with a written decision. If the employee decides not to adhere to standards, her employment with the agency is terminated. Reporting the employee to administration, documenting the employee’s behavior in her personnel file, and telling the employee that she will be fired if she calls in sick again are not appropriate initial actions. Test-Taking Strategy: Use the process of elimination, noting the strategic word “initially.” Focusing on the data in the question and noting that there is no information to indicate that this employee has been approached about his or her behavior in the past will direct you to the correct option. Review the procedure for handling unacceptable behavior related to employment standards if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 74 1 / 1 pts The nurse is working with a newly employed nurse in the clinic. A nursing staff member approaches the nurse and announces that the newly employed nurse is not using alcohol swabs to clean skin before administering intramuscular medications. What is the appropriate way for the nurse to handle this situation?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 91/117 Telling the nurse that it is inappropriate to report other nurses Providing an in-service educational session on aseptic technique for everyone in the clinic Informing the nurse who reported the occurrence that the skin does not need to be cleaned with alcohol before medication administration Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated Correct! Correct! Rationale: The skin must be cleaned with alcohol (or another antiseptic as designated by agency policy) before administering an intramuscular injection. The nurse should handle this problem directly with the nurse who is using incorrect technique by first reviewing the nurse’s skills checklist to determine whether this skill has ever been performed by the nurse and validated. There is no information in the question to indicate that an in-service educational session is needed for everyone in the clinic. As a part of professional responsibility to maintain quality care, nurses are required to report instances of clinical incompetence. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, the principles of ensuring quality care for clients. Remember that it is best for the nurse to deal directly with the employee who is exhibiting unacceptable behavior. Review the principles of handling clinical incompetence if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 92/117 Question 75 1 / 1 pts A nurse who recently learned she is pregnant has just received client assignments for the day. Which client assignment should the nurse question as being inappropriate? Correct! Correct! A client with a solid sealed cervical radiation implant A client with diarrhea for whom enteric precautions are in effect A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate A client for whom contact precautions have been implemented and who requires frequent wound irrigations7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 93/117 Rationale: Brachytherapy involves the implantation of a sealed radiation source within the targeted tumor tissue. A client who is wearing a solid implant emits radiation as long as the implant is in place; however, the client’s excreta is not radioactive. Pregnant nurses should not care for such clients. There are no contraindications to having a pregnant nurse care for a client under enteric precautions, a client with cancer who is receiving a continuous infusion of intravenous therapy, or a client who requires frequent wound irrigation. Test-Taking Strategy: Use the process of elimination, noting the strategic word “question.” This word indicates a negative event query and the need to select the client situation that could present a risk to a pregnant client. Thinking about the risks associated with each client listed in the options will direct you to the correct one. Review the guidelines associated with caring for a client with a sealed radiation implant if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 76 1 / 1 pts A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? Telling the client that it is her surgeon’s responsibility to explain the procedure Contacting the surgeon and requesting that she visit the client to answer her questions Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 94/117 Informing the client that she has the right to cancel the surgical procedure if she wishes Telling the client that she needed to ask these questions before signing the informed consent for surgery Rationale: Informed consent is the authorization by a client or a client’s legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client’s part, the nurse has the obligation to contact the surgeon. Telling the client that she needs to ask questions before signing the consent for surgery is incorrect. Although the client should be thoroughly informed before signing consent, the client has the right to ask questions thereafter. It is the surgeon’s responsibility to explain the procedure, and, if the client wishes, she has the right to cancel the surgical procedure. Although these are correct statements, they are not the most appropriate and do not address the client’s concerns. Additionally, they do not address the legal ramifications associated with informed consent. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “does not have an adequate comprehension of the procedure” and recalling that the health care provider is primarily responsible for explaining the surgical procedure to the client will direct you to the correct option. Review the issues surrounding informed consent if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 77 0 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 95/117 A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? Call the client’s health care provider. Y You Answered ou Answered Document the error in the client s chart. Report the nurse who changed the IV solution. Correct Answer Correct Answer Ask the nurse whether she intends to report the error. Rationale: The first thing the nurse who observed the error should do is ask the nurse whether she intends to report the error. As means of helping ensure client safety, all errors must be reported to the health care provider, but this is not the initial action. The client also needs to be assessed immediately. An incident report should be completed by the nurse who discovered the error (the nurse who changed the IV solution). The appropriate documentation also must be made in the client’s record by the nurse who discovered the error. If the nurse who discovered the error indicates that the error will not be reported, it may be necessary for the other nurse to contact the supervisor. Test-Taking Strategy: Use the process of elimination, noting the strategic words “do first.” Eliminate the comparable or alike options that involve reporting the error. To select from the remaining options, think about the principles of dealing with conflict. This will direct you to the direct option. Review nursing responsibilities when an error occurs if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 96/117 Question 78 1 / 1 pts A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is “uncooperative and a real pain to care for.” The nurse would most appropriately manage this issue by taking which action? Correct! Correct! Discouraging the judgmental comments Ignoring the comments made about the client Reporting the nurses comments to administration Leaving articles about judgmental opinions in the nurses report room7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 97/117 Rationale: Nurses must discuss clients in a professional manner and avoid using judgmental language such as “uncooperative” or “difficult.” When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not addressed. Leaving articles about judgmental opinions in the nurse’s report room indirectly addresses the issue. Additionally, the nurse cannot ensure that the nursing staff will read the articles. Likewise, reporting the nurses’ comments to administration does not directly address the issue. The best approach that the nurse can take is to directly discuss the issue with the staff members. This action is not identified in the options. Therefore, of the options presented, discouraging judgmental comments is the most appropriate way to manage this concern. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that do not directly address the staff’s unprofessional behavior. Review methods of discouraging judgmental comments if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 79 1 / 1 pts A client receives cefazolin sodium (Ancef) via the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the health care provider, and begins to document the reaction in an incident report. The nurse most accurately documents with which statement? The client had an allergy to cefazolin sodium.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 98/117 The health care provider was notified because a rash developed while the client was receiving cefazolin sodium. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client’s skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified. Correct! Correct! Rationale: The nurse should document relevant information in an accurate, complete, and objective form. Noting the client had an allergy to cefazolin sodium does not identify objective data. Assuming that the client is allergic to cefazolin sodium because of warm and flushed skin makes an interpretation about the occurrence. Documenting that the health care provider was notified because the client developed a rash while receiving the medication identifies accurate data but is incomplete. Test-Taking Strategy: Use knowledge of the subject, accuracy with documentation, and recall that documentation should include relevant information in an accurate, complete, and objective form. This will direct you to the correct option. Also note the relationship of the data in the question and in the correct option. Review the principles related to documentation if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Question 80 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 99/117 A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately take which action? Refuse to do the assignment. Tell the nurse manager to call the nursing supervisor. Ask the nurse manager of the intensive care unit to discuss the assignment. Correct! Correct! Return to the medical care unit and discuss the assignment with the nurse manager on that unit.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 100/117 Rationale: A nurse who feels that the assignment is more difficult than the assignments delegated to other nurses on the unit would most appropriately discuss the assignment with the nurse manager of the intensive care unit. This will help the nurse identify the rationale for the assignment or determine whether the assignment is actually more difficult. A nurse would not refuse an assignment. The nurse would not return to the medical care unit, which would constitute client abandonment. Additionally, this action does not address the conflict directly. Telling the nurse manager to call the nursing supervisor is an aggressive action that does not address the conflict directly. Test-Taking Strategy: Focus on the subject, dealing with conflict. Refusing to perform the assignment is unethical and could be grounds for dismissal. Leaving the nursing unit constitutes client abandonment and could also result in dismissal. From the remaining options, select the option in which the conflict is dealt with directly. Review the appropriate methods of dealing with a conflict if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 81 1 / 1 pts A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? Correct! Correct! Contacting the health care provider Reassessing the client in 30 minutes7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 101/117 Checking to see whether it is time for more pain medication Encouraging the client to continue active range of motion exercises of the left arm Rationale: The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. The affected client also complains that pain during passive motion is greater than that during active motion. The nurse must notify the health care provider immediately. The other options are incorrect because they delay necessary interventions. Test-Taking Strategy: Focus on the assessment data presented in the question. Recall that these signs indicate early acute compartment syndrome. Remember, if this is suspected, the health care provider needs to be notified. Also note that the incorrect options are comparable or alike options that delay necessary intervention. Review the complications associated with a fracture of an extremity and the associated priority nursing interventions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 82 1 / 1 pts A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? Pulse Urine output7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 102/117 Temperature Correct! Correct! Respiratory status Rationale: Morphine sulfate depresses respiration, so the nurse must monitor the client’s respiratory status closely. Although the incorrect options may be components of the assessment, checking respiratory status is the priority nursing action. Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Use the ABCs—airway, breathing, and circulation—to guide you to the correct option. Review priority nursing interventions in the care of a client receiving morphine sulfate if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 83 1 / 1 pts A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first take which action? Check the client s apical pulse Correct! Correct! Check the placement of the tube Check when the last feeding was given Check when the last medications were given7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 103/117 Rationale: To help prevent aspiration, the nurse checks the placement of the tube by aspirating gastric contents and measuring the pH. Checking when a feeding or medication was last given and checking the client’s apical pulse are not directly related to the subject of the question. Test-Taking Strategy: Note the strategic word “first.” Use the ABCs—airway, breathing, and circulation. To help prevent the complication of aspiration when administering medications to a client with an NG tube, the nurse must first assess accurate placement of the tube. Review the principles of administering medications through an NG tube if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 84 1 / 1 pts An nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first? Heart rate Radial pulse rate Correct! Correct! Peripheral pulses Blood pressure (BP)7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 104/117 Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment is to check the peripheral pulses to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the priority with a circumferential extremity burn is the assessment of peripheral pulses. Test-Taking Strategy: Eliminate the comparable or alike options first (heart rate and radial pulse rate). To select from the remaining options, focus on the strategic words “first” and “circumferential burns of both legs.” If you had difficulty with this question or are unfamiliar with the priority assessment in a client who has sustained a circumferential burn of an extremity, review this content. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 85 1 / 1 pts A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart for which reason? To understand the organization’s reason for existence Correct! Correct! To be familiar with the organization’s line of authority To be familiar with the beliefs and values of the organization To be aware of the geographic area that the organization serves7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 105/117 Rationale: An organizational chart depicts and communicates how activities are arranged, how authority relationships are defined, and how communication channels are established. Understanding the organization’s reason for existence, geographic area, and the beliefs and values of the organization are all components of the organization’s mission statement. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, components of an organizational chart, to answer this question. Note the relationship of the words “organizational” in the question and “lines of authority” in the correct option. Review the purpose of an organizational chart if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 86 1 / 1 pts A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital’s stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power? Correct! Correct! Expert power Reward power Referent power Coercive power7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 106/117 Rationale: Power is the ability to influence others to achieve goals. Expert power results from knowledge and skills that one possesses that is needed by others. Reward power is based on the ability to be able to grant rewards and favors. Coercive power is based on fear and the ability to punish. Referent power results from followers’ desire to identify with a powerful person. Test-Taking Strategy: Focus on the data in the question, and note that a consultation is being sought from another health care team member in the care of a client. This will direct you to the correct option. Review the types of power and the purpose of consultations if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 87 1 / 1 pts A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function? Allows the staff to make every decision regarding employee scheduling Fosters the growth of others so that they are less dependent on the leader Correct! Correct! Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 107/117 Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. Staff do not have the power to reprimand and punish or make decisions regarding scheduling or the nursing unit. Test-Taking Strategy: Think about the subject, the definition of the term “empowerment,” and use the process of elimination. Note the relationship of this definition and its relationship to the information in the correct option. Review the description of empowerment if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 88 1 / 1 pts A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the health care team does the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility? Clergy Correct! Correct! Social worker Physical therapist Occupational therapist7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 108/117 Rationale: A social worker is educated to counsel clients in a variety of areas. Counseling services may include providing emotional support for clients and families during severe and terminal illnesses, arranging placement in extended care facilities, and locating financial resources. Clergy (pastoral care) offer spiritual support and guidance to clients and families. A physical therapist assists in examining, testing, and treating the physically disabled or handicapped through the use of exercises and other techniques. An occupational therapist assists a client who experiences impairment in performing activities of daily living such as feeding himself or herself with the use of an adaptive device. Test-Taking Strategy: Use the process of elimination and focus on the subject, discharge planning. Recalling the functions and roles of the social worker and the other members of the health care team presented in the options will direct you to the correct option. Review the roles of the various health care team members if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 89 1 / 1 pts The nurse notes that a health care provider has documented the following prescription in a client’s record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? Correct! Correct! Contacting the health care provider Administering the medication Drawing up the medication in a syringe7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 109/117 Planning to have the nurse on the next shift administer the medication Rationale: The medication prescription must include the medication name, dose, route of administration, time, and frequency of the administration. The nurse would contact the health care provider and ask about the route of the medication. The nurse would not prepare the medication or administer it without first checking with the health care provider. A stat prescription must be administered immediately. Therefore it is inappropriate to plan to have the nurse on the next shift administer the medication. Test-Taking Strategy: Read the prescription and think about the subject, the procedure for fulfilling a prescription. This will reveal that the route of administration is not specified. Review components of a medication prescription if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Medication Administration Question 90 1 / 1 pts A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse provides the client with which information? Correct! Correct! She will need to sign an informed consent form. Her mother or father will need to be contacted for permission to treat her.7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 110/117 Anyone over the age of 18 years may sign a consent form for her treatment. A consent form is not needed if the problem is a sexually transmitted infection. Rationale: Informed consent is a person’s agreement to allow something, such as a treatment, to be performed. A consent form is needed if the problem is a sexually transmitted infection. If the client is a minor, he or she may sign the informed consent in the following situations: if the client is an emancipated minor; if the client is seeking birth control services or is pregnant; if the client is seeking treatment for a sexually transmitted infection, drug or substance abuse, or psychiatric services; or if a court order or other legal authorization has been obtained. Test-Taking Strategy: Eliminate the comparable or alike options that indicate that the consent form must be signed by another individual. To select from the remaining options, recall that a consent form is required for treatment. Review the issues related to informed consent if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 91 1 / 1 pts An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining lifethreatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client’s parents but is unsuccessful. What action is necessary with regard to informed consent for the surgery?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 111/117 Correct! Correct! The nurse understands that consent is not needed. The nurse will contact the hospital clergy to provide informed consent. The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature. The nurse will prepare the client to undergo mechanical ventilation until the client’s parents can be contacted. Rationale: In an emergency situation, if it is impossible to obtain consent from the client or an authorized person, the procedure required to benefit the client or save his or her life may be undertaken without informed consent. In such cases the law assumes that the client would wish to be treated. Contacting the hospital clergy to provide the informed consent and having the nurse sign on behalf of the client with another nurse to witness the signature are both incorrect. Also, having the client undergo mechanical ventilation until his parents can be contacted will delay treatment of a life-threatening injury. Test-Taking Strategy: Use the process of elimination. Noting the strategic words “life-threatening injuries” will direct you to the correct option. Review the issues regarding informed consent if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 92 0 / 1 pts A nurse is supervising a new nursing graduate in various procedures. Which action by the new nursing graduate7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 112/117 constitutes a negligent act? Giving a verbal report to the nurse on the oncoming shift Y You Answered ou Answered Checking neurological signs in a client with a head injury Correct Answer Correct Answer Using clean gloves to change a gastrostomy tube dressing Contacting a health care provider about a change in a client’s blood pressure Rationale: Common negligent acts include medication errors that result in injury to the client; intravenous therapy errors resulting in infiltrations or phlebitis; burns caused by equipment, bathing, or spills of hot liquids and foods; falls resulting in an injury; failure to use aseptic technique where required; failure to give report or giving an incomplete report to an oncoming shift; failure to adequately monitor a client’s condition; and failure to notify a health care provider of a significant change in a client’s condition. Using clean gloves is a negligent act. The nurse would use sterile gloves to change a dressing over broken skin. Test-Taking Strategy: Use the process of elimination and focus on the subject, a negligent act. Read each option carefully; note the word “clean” in the correct option. Review the concept of negligence if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 93 1 / 1 pts7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 113/117 A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client’s record reflects the correct use of guidelines for documentation? The client seems anxious. Correct! Correct! The client’s intake was 360 mL. The client’s wound is healing well. The client is voiding large amounts. Rationale: Quality documentation and reporting have five important characteristics: factual, accurate, complete, current, and organized. Using an accurate measurement of intake is correct. The use of the word “seems” indicates that the nurse did not know the facts. Using the word “well” is also incorrect, because it does not provide an accurate observation. Likewise, using the word “large” does not provide an accurate measurement. Test-Taking Strategy: Recall the characteristics of quality documentation and reporting. Also note that the correct option is the only one that is specific. Eliminate the comparable or alike options that are nonspecific. Review the guidelines for documentation if you had difficulty with this question. Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Communication and Documentation Question 94 1 / 1 pts A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 114/117 To identify health care policies in her state To know how to perform certain procedures Correct! Correct! To be aware of the role of the licensed nurse To be aware of hospital and long-term care facilities policies Rationale: A nurse practice act regulates the licensure and practice of nursing. Nurse practice acts describe in general terms what constitutes nursing practice. Actions that are considered unprofessional conduct are usually identified. Guidelines for procedures and policies are formulated by the specific health care agency. The health care policies of the state in question are not identified in a nurse practice act. Test-Taking Strategy: Use the process of elimination. Use knowledge of the subject, the purpose of the nurse practice act. Note the relationship between the words “nurse practice act” in the question and “role of the licensed nurse” in the correct option. Review the purpose of the nurse practice act if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 95 1 / 1 pts A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? Correct! Correct! Realigning the client Asking the client to wiggle her toes7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 115/117 Removing some of the traction weights Medicating the client with the prescribed analgesic Rationale: A client who complains of severe pain may need realignment or may have traction weights that are too heavy. The nurse would first realign the client and then, if this is ineffective, call the health care provider. Asking the client to wiggle her toes serves no useful purpose. The nurse never removes traction weights unless this has been specifically prescribed by the health care provider. The client should be medicated only after an effort has been made to determine and treat the cause of her pain. Test-Taking Strategy: Note the strategic word “first.” Recall the causes of pain in a client with skeletal traction and remember that the nurse first determines and treats the cause. Review care of the client in traction if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 96 1 / 1 pts A nurse is performing suctioning through an adult client’s tracheostomy tube. The nurse notes that the client’s oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? Calling the health care provider Calling the respiratory therapist Rechecking the pulse oximetry reading7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 116/117 Correct! Correct! Oxygenating the client with 100% oxygen Rationale: The nurse should monitor the client’s heart rate and pulse oximetry during suctioning to assess the client’s tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen. Although the nurse would monitor the client’s pulse oximetry, an improvement would not be expected until the client is reoxygenated. It is not necessary to contact the health care provider or the respiratory therapist at this time. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to the correct option. Review the complications associated with suctioning and the appropriate nursing interventions if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Question 97 1 / 1 pts A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? Call the health care provider. Clamp the chest tube with a Kelly clamp. Instruct the client to inhale and hold his breath. Submerge the end of the chest tube in a bottle of sterile water. Correct! Correct!7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 117/117 Rationale: If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. The health care provider must be notified, but this is not the first action. The client would not be instructed to inhale because this would cause atmospheric air to enter the pleural space. In most situations, clamping of chest tubes is contraindicated. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route.