HESI Management Of Care Module 5 Questions And Answers With
Verified Study Set Updated Solutions
** A client with leukemia is being considered for a bone marrow transplant. The healthcare 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 healthcare ethics is the team practicing?
Nonmaleficence
Autonomy
Justice
Fidelity ANS : Nonmaleficence
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.
The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. ANS : The
nurse administers an immunization to a child even though it may cause discomfort.
The nursing instructor asks a student to name an example of false imprisonment. Which of the following
situations reflects a violation of this client right?
Observing the provision of care to the client without the client's permission
Telling the client that he or she may not leave the hospital
Performing a procedure without consent
Threatening to give a client a medication against his or her will ANS : Telling the client that he or she may
not leave the hospital
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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS :
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
Verified Study Set Updated Solutions
** A client with leukemia is being considered for a bone marrow transplant. The healthcare 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 healthcare ethics is the team practicing?
Nonmaleficence
Autonomy
Justice
Fidelity ANS : Nonmaleficence
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.
The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. ANS : The
nurse administers an immunization to a child even though it may cause discomfort.
The nursing instructor asks a student to name an example of false imprisonment. Which of the following
situations reflects a violation of this client right?
Observing the provision of care to the client without the client's permission
Telling the client that he or she may not leave the hospital
Performing a procedure without consent
Threatening to give a client a medication against his or her will ANS : Telling the client that he or she may
not leave the hospital
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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS : 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 ANS :
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
