HESI LPN Med-Surg Exam – Medical-Surgical Nursing Questions, Answers & Study Guide

LPNBFMedBFSurgBFHESI


TheBFnurseBFisBFprovidingBFcareBFforBFaBFpatientBFwhoBFisBFunhappyBFwithBFth
eBFhealthBFcareBFprovider'sBFcare.BFTheBFpatientBFsignsBFtheBFAgainstBFMedic
alBFAdviceBF(AMA)BFformBFandBFleavesBFtheBFhospitalBFagainstBFmedicalBFad
vice.BFWhatBFshouldBFtheBFnurseBFincludeBFinBFtheBFdocumentationBFofBFthisBF
eventBFinBFtheBFpatient'sBFmedicalBFrecordBForBFonBFtheBFAMABFform?BFSelec
tBFallBFthatBFapply.


1.BFDocumentationBFthatBFtheBFpatientBFwasBFinformedBFthatBFheBForBFsheBFca
nnotBFcomeBFbackBFtoBFtheBFhospitalBF
2.BFDocumentationBFthatBFtheBFpatientBFwasBFinformedBFthatBFheBForBFsheBFwa
sBFleavingBFagainstBFmedicalBFadviceBF
3.BFDocumentationBFthatBFtheBFrisksBFofBFleavingBFagainstBFmedicalBFadviceB
FwereBFexplainedBFtoBFtheBFpatientBF



4.BFDocumentationBFofBFanyBFdischargeBFinstructionsBFgivenBFtoBFtheBFpatien
tBF
5.BFDocumentationBFindicatingBFanBFincidentBFreportBFhasBFbeenBFcompleted
BF-BFcorrectBFanswer✔ ✔
2,3,4BFRationaleBF1:BFItBFshouldBFbeBFclearlyBFdocumentedBFthatBFtheBFpatie
ntBFwasBFadvisedBFandBFunderstandsBFthatBFheBForBFsheBFcanBFcomeBFback.BFR
ationaleBF2:BFItBFshouldBFbeBFclearlyBFdocumentedBFinBFtheBFpatient'srecordBF
andBFonBFtheBFAMABFformBFthatBFtheBFpatientBFwasBFadvisedBFthatBFheBForBFsh
eBFwasBFleavingBFagainstBFmedicalBFadvice.BFRationaleBF3:BFItBFshouldBFbeBFcl
earlyBFdocumentedBFthatBFtheBFpatientBFunderstandstheBFrisksBFofBFleavingBF
againstBFmedicalBFadvice.BFRationaleBF4:BFTheBFAMABFformBFincludesBFtheBF

,nameBFofBFtheBFpersonBFaccompanyingBFtheBFpatientBFandBFanyBFdischargeBFi
nstructionsBFgiven.BFRationaleBF5:BFFacilityBFpolicyBFmayBFrequireBFthatBFanB
FincidentBFreportBFbeBFcompleted,BFbutBFitBFmustBFnotBFbeBFreferencedBFinBFth


eBFchart.BFTheBFpatient'srecordBFisBFaBFlegalBFdocument,BFsoBFtheBFnurseBFsho
uldBFneverBFdocumentBFthatBFheBForBFsheBFfiledBFanBFincidentBFreport.


ABFnurseBFdocumentsBFthisBFstatementBFinBFaBFpatient'sBFmedicalBFrecord:BF"
2/25/-
,BF2235.BFAtBF2015BFpatientBFawokeBFsuddenlyBFandBFcomplainedBFofBFshortn
essBFofBFair.BFPulseBFoximetryBFreadingBFwasBF82%BFonBFroomBFairBFandBFaud
ibleBFwheezesBFcouldBFbeBFheard."BFThisBFdocumentationBFmeetsBFwhichBFdo
cumentationBFguidelines?BFSATA
1.BFDocumentationBFistimelyBF
2.BFDocumentationBFisBFconciseBF
3.BFDocumentationBFisBFobjectiveBF
4.BFDocumentationBFincludesBFdateBFandBFtimeBFofBFentryBF

5.BFDocumentationBFisBFcompleteBFandBFaccurateBF-BFcorrectBFanswer✔ ✔
2,3,4,5BFRationaleBF1:BFTheBFnurseBFshouldBFdocumentBFasBFsoonBFasBFposs
ibleBFafterBFanBFobservationBFisBFmadeBForBFcareBFisBFprovided.BFTheBFentryBF
wasBFmadeBFinBFtheBFpatient'sBFmedicalBFrecordBFatBFleastBF2BFhoursBFafterBFth
eBFpatientBFcomplaintBFandBFshouldBFbeBFlabeledBFlateBFentry.BFRationaleBF2:B
FThisBFentryBFdescribesBFtheBFsituation BFfullyBFbutBFisBFconcise.BFRationaleBF3


:BFTheBFnurseBFdescribesfactualBFeventsBFthatBFcanBFbeBFseen,BFheard,BFsmell
ed,BForBFtouched.BFItBFisBFimportantBFtoBFbeBFobjectiveBFandBFavoidBFvagueBFst
atementsBFthatBFareBFsubjective.BFRationaleBF4:BFBothBFtheBFdateBFandBFtheBFti
meBFofBFtheBFentryBFareBFdocumented.BFRationaleBF5:BFTheBFnurseBFshouldBFd
ocumentBFonlyBFfacts:BFwhatBFheBForBFsheBFcanBFsee,BFhear,BFandBFdo.

,ABFnurseBFdocumentsBFtheBFfollowingBFinBFaBFpatient'sBFmedicalBFrecord:BF"2
/1/BF,BF1500.BFPatientBFappearsBFweakBFandBFfaint.BFPatient'sBFskinBFisBFmoistB
FandBFcool,BFvomitedBFbrightBFredBFbloodBFwithBFclots.BFHealthBFcareBFprovid


erBFnotifiedBFandBForderBFreceivedBFtoBFgiveBF2BFuBFofBFpackedBFredBFbloodBFc
ellsBFifBFstatBFHgbBFisBF<BF8.0.BFPainBFmedicationBFwillBFbeBFgiven."BFThisBFdo
cumentationBFmeetsBFwhichBFdocumentationBFprinciple?
1.BFDocumentBFobjectively.BF
2.BFDoBFnotBFdocumentBFproceduresBFinBFadvance.BF
3.BFUseBFapprovedBFabbreviations.BF

4.BFDocumentBFchangesBFinBFpatientBFconditionBF-BFcorrectBFanswer✔ ✔
4


InBFgeneral,BFemployersBFasBFwellBFasBFstate,BFfederal,BFandBFprofessionalBFst
andardsBFrequireBFdocumentationBFtoBFincludeBFinitialBFandBFongoingBFasses
sments,BFanyBFchangeBFinBFtheBFpatient'sBFcondition,BFtherapiesBFgivenBFandBF
patientBFresponse,BFpatientBFteaching,BFandBFrelevantBFstatementsBFbyBFtheBF
patient.


ABFnursingBFunitBFhasBFchangedBFitsBFdocumentationBFsystemBFtoBFdocument
ingBFbyBFexception.BFHowBFwillBFthisBFsystemBFsaveBFtime?BF
1.BFItBFeliminatesBFlengthyBForBFrepetitiveBFdocumentation.BF
2.BFItBFallowsBFflexibilityBFandBFdescriptionBFinBFtheBFdocumentation.BF

, 3.BFItBFallowsBFtheBFreaderBFtoBFeasilyBFlocateBFinformationBFaboutBFaBFspecifi
cBFproblem.BF
4.BFItBFallowsBFforBFquickBFandBFeasyBFretrievalBFofBFinformation.BF-
BFcorrectBFanswer✔ ✔
1BFRationaleBF1:BFDocumentingBFbyBFexceptionBFeliminatesBFlengthyBForBF
repetitiveBFdocumentation.BFRationaleBF2:BFFlexibleBFandBFdescriptiveBFdoc
umentationBFisBFanBFadvantageBFofBFtheBFnarrativeBFsystem.BFRationaleBF3:BF
PIEBFchartingBFallowsBFeasyBFlocationBFofBFinformationBFaboutBFaBFspecificBF
problem.BFRationaleBF4:BFTheBFelectronicBFhealthBFrecordBFallowsforBFquick
BFandBFeasyBFretrievalBFofBFinformation.




ABFhospitalBFisBFconsideringBFchangingBFitsBFdocumentationBFsystemBFtoBFre
duceBFtheBFnumberBFofBFmedicationBFerrors.BFWhichBFsystemBFshouldBFtheBFh
ospitalBFinvestigate?BF
1.BFProblem,BFintervention,BFevaluationBF(PIE)systemBF
2.BFElectronicBFmedicalBFrecordBF
3.BFProblem-orientedBFmedicalBFrecordBF

4.BFNarrativeBFsystemBF-BFcorrectBFanswer✔ ✔ 2

TheBFelectronicBFmedicalBFrecordBFdecreasesBFerrorsBFandBFallowsBFforBFtheBF
reconciliationBFofBFtheBFpatient'sBFmedicationsBFonBFadmission,BFdaily,BFandB
FonBFdischarge.




WhichBFnursingBFactivitiesBFareBFexamplesBFofBFindependentBFfunctionsBFofB
FtheBFnursing BFrole? BF