HESI VN Exam Prep Questions with Answers 2023/2024 (Already Graded A+)

HESI VN Exam Prep Questions with Answers 2023/2024 (Already Graded A+) A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes Question 9 1 / 1 pts Coro rer ct!t Ask the client for permission to lock the necklace in the hospital safe. 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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. Coro rer ct!t 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 Care Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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 Coro rer ct! Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms 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-ray Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 13/117 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? Coro rer ct!t Contacting the nursing supervisor Continuing to transcribe the prescription Question 11 1 / 1 pts 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 14/117 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? Question 12 1 / 1 pts 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 15/117 Question 13 1 / 1 pts Call the nursing supervisor. Explain the procedure to the client, then remove the chest tube. Coro rer ct!t Inform the health care provider that removal of a chest tube is not a nursing procedure. 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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? Coro rer ct!t Calling the health care provider who gave the telephone prescription to clarify the prescription 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 department Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 17/117 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 prescription Question 14 1 / 1 pts 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 18/117 Question 15 1 / 1 pts Coro rer ct!t Asking the health care provider to write the prescription in the client’s record before leaving the nursing unit 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 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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 Coro rer ct! Calling the surgeon and asking that the risks be explained to the client 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/Legal Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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. Coro rer ct! 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.