Module 5 HESI Management of Care | Questions and
Answers(A+ Solution guide)
A nurse and a nursing assistant enter a client's room to provide care and find the
client lying on the floor. The nurse should first:
Ask the nursing assistant to assist in getting the client back to bed
Ask the nursing assistant to complete an incident report
Contact the unit secretary on the intercom and ask that the client's primary health
care provider be called
Check the client's level of consciousness and vital signs - ANSWER -Check the
client's level of consciousness and vital signs
Which of the following actions exemplifies the use of evidence-based practice in
the delivery of client care?
Donning sterile gloves to change an abdominal wound dressing
Advising a client to agree to the treatment recommended by her primary health
care provider
Taking a rectal temperature from a client for whom bleeding precautions have been
instituted
Encouraging a client to take an herbal substance to treat his insomnia - ANSWER
-Donning sterile gloves to change an abdominal wound dressing
The registered nurse has accepted a new position as case manager in a hospital.
Which of the following responsibilities are part of the nurse's new role? Select all
that apply.
Assessing the client's needs for home supplies and equipment
Prescribing treatments specific to the client's needs
Evaluating and updating the plan of care as needed
Coordinating consultations and referrals to facilitate discharge
Establishing a safe and cost-effective plan of care with the client - ANSWER -
Evaluating and updating the plan of care as needed
,Assessing the client's needs for home supplies and equipment
Coordinating consultations and referrals to facilitate discharge
Establishing a safe and cost-effective plan of care with the client
The nurse manager of a quality improvement program asks a nurse in the
neurological unit to conduct a retrospective audit. Which of the following actions
should the auditing nurse plan to perform in this type of audit?
Obtaining the assigned medical record from the hospital's medical record room to
review documentation made during a client's hospital stay
Checking the crash cart to ensure that all needed supplies are readily available
should an emergency arise
Checking the documentation written by a new nursing graduate on her assigned
clients at the end of the shift
Reviewing neurological assessment checklists for all clients on the unit to ensure
that these assessments are being conducted as prescribed - ANSWER -Obtaining
the assigned medical record from the hospital's medical record room to review
documentation made during a client's hospital stay
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
Ask the client to remove the necklace and place it in the top drawer of the bedside
table
Ask the client for permission to lock the necklace in the hospital safe
Ask the client to sign a release to free the hospital of responsibility if the necklace
is damaged or lost during the procedure - ANSWER -Ask the client for permission
to lock the necklace in the hospital safe
,A nurse providing preoperative care to a client who is scheduled for a left
mastectomy and axillary lymph node dissection notes that the client is wearing a
wedding band on her left ring finger. The nurse should:
Tape the wedding band in place
Explain to the client why the wedding band must be removed
Ask the client to sign a release to free the hospital of responsibility if the wedding
band is lost during surgery
Ask the client whether she would like to remove the wedding band or wear it to
surgery - ANSWER -Explain to the client why the wedding band must be removed
** A nurse preparing a client to go to the radiology department for a chest 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
Asking the client to place the medal in the top drawer of the bedside stand just
before leaving for the radiology department
Assisting the client in pinning the medal and chain to the waistband of the client's
pajama bottoms
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 - ANSWER -Assisting the
client in pinning the medal and chain to the waistband of the client's pajama
bottoms
** A physician 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 physician, 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?
Contact the nursing supervisor
Ask the nurse assigned to care for the client to administer the medication
Verify the prescribed dose with the client before administering the medication
, Continue to transcribe the prescription - ANSWER -Contacting the nursing
supervisor
** A 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 physician. The physician 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. The nurse should first:
Explain the procedure to the client, then remove the chest tube
Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing
the chest tube
Call the nursing supervisor
Inform the primary health care provider that removal of a chest tube is not a
nursing procedure - ANSWER -Inform the physician that removal of a chest tube
is not a nursing procedure
A nurse calls a physician to report that a client with congestive heart failure (CHF)
is exhibiting dyspnea and worsening of wheezing. The physician, 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?
The nurse calls a primary health care provider to report that a client with
congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing.
The primary health care provider, who is in a hurry because of a situation in the
emergency department, gives the nurse a telephone prescription for furosemide but
does not specify the route of administration. What is the appropriate action on the
part of the nurse?
Call the nursing supervisor for assistance in determining the route of
administration
Administer the medication ora - ANSWER -Calling the primary health care
provider who gave the telephone prescription to clarify the prescription
Answers(A+ Solution guide)
A nurse and a nursing assistant enter a client's room to provide care and find the
client lying on the floor. The nurse should first:
Ask the nursing assistant to assist in getting the client back to bed
Ask the nursing assistant to complete an incident report
Contact the unit secretary on the intercom and ask that the client's primary health
care provider be called
Check the client's level of consciousness and vital signs - ANSWER -Check the
client's level of consciousness and vital signs
Which of the following actions exemplifies the use of evidence-based practice in
the delivery of client care?
Donning sterile gloves to change an abdominal wound dressing
Advising a client to agree to the treatment recommended by her primary health
care provider
Taking a rectal temperature from a client for whom bleeding precautions have been
instituted
Encouraging a client to take an herbal substance to treat his insomnia - ANSWER
-Donning sterile gloves to change an abdominal wound dressing
The registered nurse has accepted a new position as case manager in a hospital.
Which of the following responsibilities are part of the nurse's new role? Select all
that apply.
Assessing the client's needs for home supplies and equipment
Prescribing treatments specific to the client's needs
Evaluating and updating the plan of care as needed
Coordinating consultations and referrals to facilitate discharge
Establishing a safe and cost-effective plan of care with the client - ANSWER -
Evaluating and updating the plan of care as needed
,Assessing the client's needs for home supplies and equipment
Coordinating consultations and referrals to facilitate discharge
Establishing a safe and cost-effective plan of care with the client
The nurse manager of a quality improvement program asks a nurse in the
neurological unit to conduct a retrospective audit. Which of the following actions
should the auditing nurse plan to perform in this type of audit?
Obtaining the assigned medical record from the hospital's medical record room to
review documentation made during a client's hospital stay
Checking the crash cart to ensure that all needed supplies are readily available
should an emergency arise
Checking the documentation written by a new nursing graduate on her assigned
clients at the end of the shift
Reviewing neurological assessment checklists for all clients on the unit to ensure
that these assessments are being conducted as prescribed - ANSWER -Obtaining
the assigned medical record from the hospital's medical record room to review
documentation made during a client's hospital stay
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
Ask the client to remove the necklace and place it in the top drawer of the bedside
table
Ask the client for permission to lock the necklace in the hospital safe
Ask the client to sign a release to free the hospital of responsibility if the necklace
is damaged or lost during the procedure - ANSWER -Ask the client for permission
to lock the necklace in the hospital safe
,A nurse providing preoperative care to a client who is scheduled for a left
mastectomy and axillary lymph node dissection notes that the client is wearing a
wedding band on her left ring finger. The nurse should:
Tape the wedding band in place
Explain to the client why the wedding band must be removed
Ask the client to sign a release to free the hospital of responsibility if the wedding
band is lost during surgery
Ask the client whether she would like to remove the wedding band or wear it to
surgery - ANSWER -Explain to the client why the wedding band must be removed
** A nurse preparing a client to go to the radiology department for a chest 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
Asking the client to place the medal in the top drawer of the bedside stand just
before leaving for the radiology department
Assisting the client in pinning the medal and chain to the waistband of the client's
pajama bottoms
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 - ANSWER -Assisting the
client in pinning the medal and chain to the waistband of the client's pajama
bottoms
** A physician 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 physician, 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?
Contact the nursing supervisor
Ask the nurse assigned to care for the client to administer the medication
Verify the prescribed dose with the client before administering the medication
, Continue to transcribe the prescription - ANSWER -Contacting the nursing
supervisor
** A 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 physician. The physician 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. The nurse should first:
Explain the procedure to the client, then remove the chest tube
Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing
the chest tube
Call the nursing supervisor
Inform the primary health care provider that removal of a chest tube is not a
nursing procedure - ANSWER -Inform the physician that removal of a chest tube
is not a nursing procedure
A nurse calls a physician to report that a client with congestive heart failure (CHF)
is exhibiting dyspnea and worsening of wheezing. The physician, 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?
The nurse calls a primary health care provider to report that a client with
congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing.
The primary health care provider, who is in a hurry because of a situation in the
emergency department, gives the nurse a telephone prescription for furosemide but
does not specify the route of administration. What is the appropriate action on the
part of the nurse?
Call the nursing supervisor for assistance in determining the route of
administration
Administer the medication ora - ANSWER -Calling the primary health care
provider who gave the telephone prescription to clarify the prescription
