LPN MED SURG HESI EXAM QUESTIONS
AND ANSWERS 100% CORRECT!!
,The nurse is providing care for a patient who is unhappy with the health care provider's
care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital
against medical advice. What should the nurse include in the documentation of this
event in the patient's medical record or on the AMA form? Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back to the
hospital
2. Documentation that the patient was informed that he or she was leaving against
medical advice
3. Documentation that the risks of leaving against medical advice were explained to the
patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed - ANSWER 2,3,4
Rationale 1: It should be clearly documented that the patient was advised and
understands that he or she can come back. Rationale 2: It should be clearly
documented in the patient'srecord and on the AMA form that the patient was advised
that he or she was leaving against medical advice. Rationale 3: It should be clearly
documented that the patient understandsthe risks of leaving against medical advice.
Rationale 4: The AMA form includes the name of the person accompanying the patient
and any discharge instructions given. Rationale 5: Facility policy may require that an
incident report be completed, but it must not be referenced in the chart. The
patient'srecord is a legal document, so the nurse should never document that he or she
filed an incident report.
A nurse documents this statement in a patient's medical record: "2/25/-, 2235. At 2015
patient awoke suddenly and complained of shortness of air. Pulse oximetry reading was
82% on room air and audible wheezes could be heard." This documentation meets
which documentation guidelines? SATA
1. Documentation istimely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate - ANSWER 2,3,4,5 Rationale 1: The nurse
should document as soon as possible after an observation is made or care is provided.
The entry was made in the patient's medical record at least 2 hours after the patient
complaint and should be labeled late entry. Rationale 2: This entry describes the
situation fully but is concise. Rationale 3: The nurse describesfactual events that can be
seen, heard, smelled, or touched. It is important to be objective and avoid vague
statements that are subjective. Rationale 4: Both the date and the time of the entry are
,documented. Rationale 5: The nurse should document only facts: what he or she can
see, hear, and do.
Which nursing activities are examples of independent functions of the nursing role?
1. Teaching a soon-to-be-discharged patient about the medication regimen that the
health care provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene
activities while in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by
occupational therapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical
health status - ANSWER 2,5 Rationale 1: Teaching the patient about medications
prescribed by the health care provider is an interdependent activity. Rationale 2: This
activity is part of the assessment process, which is an independent activity that nurses
may perform, based on their education and skills. Rationale 3: Working in coordination
with another health team member is an interdependent activity. Rationale 4:
Administering medication prescribed by the health care provider is an example of a
dependent activity. Rationale 5: These activities are included in assessment, which is
an independent activity that nurses may perform, based on their education and skills.
The nurse is caring for a 70-year-old patient who was just admitted to an inpatient
rehabilitation center. The patient had required total parenteral nutrition for several days,
but recently resumed and is tolerating a regular diet. She has another 4 days left in a
course of intravenous antibiotics to complete treatment of a positive central line culture.
Which nursing action, required in the care of this patient, is considered a dependent role
function?
1. Requesting that the health care provider order a consult because the patient states
that her dentures no longer fit properly and she has trouble chewing
2. Asking the nursing assistant to demonstrate to the patient how to operate the call
system
3. Interviewing the patient to assess whether she needs assistance with getting out of
bed
4. Administering the antibiotics prescribed by the health care provider - ANSWER 4
Rationale 1: Assessing that the patient has a need that requires further assessment by
other team members and communicating that need to the appropriate team member is
an example of an interdependent activity. Rationale 2: This is an independent activity
that nurses may perform or delegate, based on their and the delegate's education and
skills. Rationale 3: Assessment is an independent activity that nurses may perform,
based on their education and skills. Rationale 4: Dependent activities are those
prescribed by the health care provider and carried out by the nurse
, When asking a patient if a pain medication provided a few hours ago has been effective,
the nurse is performing which step of the nursing process?
1. Planning
2. Implementation
3. Evaluation
4. Assessment - ANSWER 3 Rationale 1: Planning consists of prioritizing among the
chosen nursing diagnoses and determining interventions to move the patient to optimal
health. Rationale 2: Implementation isthe actual "doing" step of the nursing process. In
this case, implementation occurred when the medication was administered. Rationale 3:
Evaluation focuses on a patient's behavioral changes and compares them with the
criteria stated in the objectives. It consists of both the patient's status and the
effectiveness of the nursing care. Both must be evaluated continuously, with the care
plan modified as needed. Rationale 4: Assessment comprises examining the patient
and identifying cues, collecting and analyzing data, and reaching conclusions. In this
situation, assessment occurred when the nurse identified that the patient was in pain
The nursing instructor knows that further education is needed when a student makes
which statement?
1. "Assessment precedes nursing diagnosis and outcome identification."
2. "Planning follows nursing diagnosis and outcome identification and precedes
implementation."
3. "Evaluation follows implementation and precedes planning."
4. "Planning follows assessment and precedes evaluation." - ANSWER 3 Rationale 1:
The correct order is assessment, diagnosis, planning, implementation, and evaluation.
Rationale 2: The correct order is assessment, diagnosis, planning, implementation, and
evaluation. Rationale 3: The correct order is assessment, diagnosis, planning,
implementation, and evaluation. Rationale 4: The correct order is assessment,
diagnosis, planning, implementation, and evaluation.
A 16-year-old patient has been admitted for treatment of presumptive pelvic
inflammatory disease. The patient's hygiene is poor and she reports living "on the
street" for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10
scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome
statement is appropriate?
1. The patient's comfort will be achieved and maintained.
2. The patient will be discharged to a safe living environment.
3. The patient will be reunited with her parents.
4. The patient's infection will be eradicated. - ANSWER 1 Rationale 1: Achieving and
maintaining comfort addresses the nursing diagnosis of acute pain related to possible
pelvic inflammatory disease identified by the nurse.
AND ANSWERS 100% CORRECT!!
,The nurse is providing care for a patient who is unhappy with the health care provider's
care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital
against medical advice. What should the nurse include in the documentation of this
event in the patient's medical record or on the AMA form? Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back to the
hospital
2. Documentation that the patient was informed that he or she was leaving against
medical advice
3. Documentation that the risks of leaving against medical advice were explained to the
patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed - ANSWER 2,3,4
Rationale 1: It should be clearly documented that the patient was advised and
understands that he or she can come back. Rationale 2: It should be clearly
documented in the patient'srecord and on the AMA form that the patient was advised
that he or she was leaving against medical advice. Rationale 3: It should be clearly
documented that the patient understandsthe risks of leaving against medical advice.
Rationale 4: The AMA form includes the name of the person accompanying the patient
and any discharge instructions given. Rationale 5: Facility policy may require that an
incident report be completed, but it must not be referenced in the chart. The
patient'srecord is a legal document, so the nurse should never document that he or she
filed an incident report.
A nurse documents this statement in a patient's medical record: "2/25/-, 2235. At 2015
patient awoke suddenly and complained of shortness of air. Pulse oximetry reading was
82% on room air and audible wheezes could be heard." This documentation meets
which documentation guidelines? SATA
1. Documentation istimely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate - ANSWER 2,3,4,5 Rationale 1: The nurse
should document as soon as possible after an observation is made or care is provided.
The entry was made in the patient's medical record at least 2 hours after the patient
complaint and should be labeled late entry. Rationale 2: This entry describes the
situation fully but is concise. Rationale 3: The nurse describesfactual events that can be
seen, heard, smelled, or touched. It is important to be objective and avoid vague
statements that are subjective. Rationale 4: Both the date and the time of the entry are
,documented. Rationale 5: The nurse should document only facts: what he or she can
see, hear, and do.
Which nursing activities are examples of independent functions of the nursing role?
1. Teaching a soon-to-be-discharged patient about the medication regimen that the
health care provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene
activities while in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by
occupational therapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical
health status - ANSWER 2,5 Rationale 1: Teaching the patient about medications
prescribed by the health care provider is an interdependent activity. Rationale 2: This
activity is part of the assessment process, which is an independent activity that nurses
may perform, based on their education and skills. Rationale 3: Working in coordination
with another health team member is an interdependent activity. Rationale 4:
Administering medication prescribed by the health care provider is an example of a
dependent activity. Rationale 5: These activities are included in assessment, which is
an independent activity that nurses may perform, based on their education and skills.
The nurse is caring for a 70-year-old patient who was just admitted to an inpatient
rehabilitation center. The patient had required total parenteral nutrition for several days,
but recently resumed and is tolerating a regular diet. She has another 4 days left in a
course of intravenous antibiotics to complete treatment of a positive central line culture.
Which nursing action, required in the care of this patient, is considered a dependent role
function?
1. Requesting that the health care provider order a consult because the patient states
that her dentures no longer fit properly and she has trouble chewing
2. Asking the nursing assistant to demonstrate to the patient how to operate the call
system
3. Interviewing the patient to assess whether she needs assistance with getting out of
bed
4. Administering the antibiotics prescribed by the health care provider - ANSWER 4
Rationale 1: Assessing that the patient has a need that requires further assessment by
other team members and communicating that need to the appropriate team member is
an example of an interdependent activity. Rationale 2: This is an independent activity
that nurses may perform or delegate, based on their and the delegate's education and
skills. Rationale 3: Assessment is an independent activity that nurses may perform,
based on their education and skills. Rationale 4: Dependent activities are those
prescribed by the health care provider and carried out by the nurse
, When asking a patient if a pain medication provided a few hours ago has been effective,
the nurse is performing which step of the nursing process?
1. Planning
2. Implementation
3. Evaluation
4. Assessment - ANSWER 3 Rationale 1: Planning consists of prioritizing among the
chosen nursing diagnoses and determining interventions to move the patient to optimal
health. Rationale 2: Implementation isthe actual "doing" step of the nursing process. In
this case, implementation occurred when the medication was administered. Rationale 3:
Evaluation focuses on a patient's behavioral changes and compares them with the
criteria stated in the objectives. It consists of both the patient's status and the
effectiveness of the nursing care. Both must be evaluated continuously, with the care
plan modified as needed. Rationale 4: Assessment comprises examining the patient
and identifying cues, collecting and analyzing data, and reaching conclusions. In this
situation, assessment occurred when the nurse identified that the patient was in pain
The nursing instructor knows that further education is needed when a student makes
which statement?
1. "Assessment precedes nursing diagnosis and outcome identification."
2. "Planning follows nursing diagnosis and outcome identification and precedes
implementation."
3. "Evaluation follows implementation and precedes planning."
4. "Planning follows assessment and precedes evaluation." - ANSWER 3 Rationale 1:
The correct order is assessment, diagnosis, planning, implementation, and evaluation.
Rationale 2: The correct order is assessment, diagnosis, planning, implementation, and
evaluation. Rationale 3: The correct order is assessment, diagnosis, planning,
implementation, and evaluation. Rationale 4: The correct order is assessment,
diagnosis, planning, implementation, and evaluation.
A 16-year-old patient has been admitted for treatment of presumptive pelvic
inflammatory disease. The patient's hygiene is poor and she reports living "on the
street" for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10
scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome
statement is appropriate?
1. The patient's comfort will be achieved and maintained.
2. The patient will be discharged to a safe living environment.
3. The patient will be reunited with her parents.
4. The patient's infection will be eradicated. - ANSWER 1 Rationale 1: Achieving and
maintaining comfort addresses the nursing diagnosis of acute pain related to possible
pelvic inflammatory disease identified by the nurse.
