Module 5 HESI Management of Care | 100% Verified
Questions and Answers (A+ Solution guide)
____________________________________________________________
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
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 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:
✓ 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?
✓ 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?
, ✓ 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:
✓ 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?
✓ Calling the physician who gave the telephone prescription to clarify the prescription
A nurse is assisting a physician in assessing a hospitalized client. During the assessment,
the physician is paged to report to the recovery room. The physician 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 appropriate nursing action in this
situation?
✓ Asking the physician to write the prescription in the client's record before leaving the
nursing unit
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:
✓ Calling the surgeon and asking that the risks be explained to the client
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 of the following statements accurately describes the
nurse's response to the client?
✓ The nurse could be charged with assault.
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. The most appropriate action for the
nurse is to:
✓ Report the incident to the nursing supervisor
A nurse calls a physician to question a prescription written for a higher-than-normal
dosage of morphine sulfate. The physician 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 physician was called to clarify the prescription for morphine sulfate.
A charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen
to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an
odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol
intoxication. The charge nurse would most appropriately:
✓ Send the staff member home
A client asks a nurse about the procedure for becoming an organ donor. The nurse tells
the client:
✓ That anatomical gifts must be made in writing and signed by the client
A nurse enters a client's room to administer a medication that has been prescribed by the
physician. The client asks the nurse about the medication. Which response by the nurse is
appropriate?
✓ "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."
Questions and Answers (A+ Solution guide)
____________________________________________________________
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
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 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:
✓ 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?
✓ 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?
, ✓ 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:
✓ 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?
✓ Calling the physician who gave the telephone prescription to clarify the prescription
A nurse is assisting a physician in assessing a hospitalized client. During the assessment,
the physician is paged to report to the recovery room. The physician 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 appropriate nursing action in this
situation?
✓ Asking the physician to write the prescription in the client's record before leaving the
nursing unit
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:
✓ Calling the surgeon and asking that the risks be explained to the client
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 of the following statements accurately describes the
nurse's response to the client?
✓ The nurse could be charged with assault.
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. The most appropriate action for the
nurse is to:
✓ Report the incident to the nursing supervisor
A nurse calls a physician to question a prescription written for a higher-than-normal
dosage of morphine sulfate. The physician 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 physician was called to clarify the prescription for morphine sulfate.
A charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen
to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an
odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol
intoxication. The charge nurse would most appropriately:
✓ Send the staff member home
A client asks a nurse about the procedure for becoming an organ donor. The nurse tells
the client:
✓ That anatomical gifts must be made in writing and signed by the client
A nurse enters a client's room to administer a medication that has been prescribed by the
physician. The client asks the nurse about the medication. Which response by the nurse is
appropriate?
✓ "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."
