LPN Med Surg HESI exam with answers
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 |- |correct |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 |- |correct |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.
A |nurse |documents |the |following |in |a |patient's |medical |record: |"2/1/ |, |1500. |Patient |appears |weak |
and |faint. |Patient's |skin |is |moist |and |cool, |vomited |bright |red |blood |with |clots. |Health |care |
provider |notified |and |order |received |to |give |2 |u |of |packed |red |blood |cells |if |stat |Hgb |is |< |8.0. |Pain |
medication |will |be |given." |This |documentation |meets |which |documentation |principle?
1. |Document |objectively. |
2. |Do |not |document |procedures |in |advance. |
3. |Use |approved |abbreviations. |
4. |Document |changes |in |patient |condition |- |correct |answer |-4
In |general, |employers |as |well |as |state, |federal, |and |professional |standards |require |documentation |
to |include |initial |and |ongoing |assessments, |any |change |in |the |patient's |condition, |therapies |given |
and |patient |response, |patient |teaching, |and |relevant |statements |by |the |patient.
A |nursing |unit |has |changed |its |documentation |system |to |documenting |by |exception. |How |will |this |
system |save |time? |
1. |It |eliminates |lengthy |or |repetitive |documentation. |
2. |It |allows |flexibility |and |description |in |the |documentation. |
3. |It |allows |the |reader |to |easily |locate |information |about |a |specific |problem. |
4. |It |allows |for |quick |and |easy |retrieval |of |information. |- |correct |answer |-1 |Rationale |1: |
Documenting |by |exception |eliminates |lengthy |or |repetitive |documentation. |Rationale |2: |Flexible |
and |descriptive |documentation |is |an |advantage |of |the |narrative |system. |Rationale |3: |PIE |charting |
allows |easy |location |of |information |about |a |specific |problem. |Rationale |4: |The |electronic |health |
record |allowsfor |quick |and |easy |retrieval |of |information.
A |hospital |is |considering |changing |its |documentation |system |to |reduce |the |number |of |medication |
errors. |Which |system |should |the |hospital |investigate? |
1. |Problem, |intervention, |evaluation |(PIE)system |
2. |Electronic |medical |record |
3. |Problem-oriented |medical |record |
4. |Narrative |system |- |correct |answer |-2
,The |electronic |medical |record |decreases |errors |and |allows |for |the |reconciliation |of |the |patient's |
medications |on |admission, |daily, |and |on |discharge.
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
|- |correct |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 |- |correct |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 |- |correct |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." |- |correct |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. |
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 |- |correct |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 |- |correct |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.
A |nurse |documents |the |following |in |a |patient's |medical |record: |"2/1/ |, |1500. |Patient |appears |weak |
and |faint. |Patient's |skin |is |moist |and |cool, |vomited |bright |red |blood |with |clots. |Health |care |
provider |notified |and |order |received |to |give |2 |u |of |packed |red |blood |cells |if |stat |Hgb |is |< |8.0. |Pain |
medication |will |be |given." |This |documentation |meets |which |documentation |principle?
1. |Document |objectively. |
2. |Do |not |document |procedures |in |advance. |
3. |Use |approved |abbreviations. |
4. |Document |changes |in |patient |condition |- |correct |answer |-4
In |general, |employers |as |well |as |state, |federal, |and |professional |standards |require |documentation |
to |include |initial |and |ongoing |assessments, |any |change |in |the |patient's |condition, |therapies |given |
and |patient |response, |patient |teaching, |and |relevant |statements |by |the |patient.
A |nursing |unit |has |changed |its |documentation |system |to |documenting |by |exception. |How |will |this |
system |save |time? |
1. |It |eliminates |lengthy |or |repetitive |documentation. |
2. |It |allows |flexibility |and |description |in |the |documentation. |
3. |It |allows |the |reader |to |easily |locate |information |about |a |specific |problem. |
4. |It |allows |for |quick |and |easy |retrieval |of |information. |- |correct |answer |-1 |Rationale |1: |
Documenting |by |exception |eliminates |lengthy |or |repetitive |documentation. |Rationale |2: |Flexible |
and |descriptive |documentation |is |an |advantage |of |the |narrative |system. |Rationale |3: |PIE |charting |
allows |easy |location |of |information |about |a |specific |problem. |Rationale |4: |The |electronic |health |
record |allowsfor |quick |and |easy |retrieval |of |information.
A |hospital |is |considering |changing |its |documentation |system |to |reduce |the |number |of |medication |
errors. |Which |system |should |the |hospital |investigate? |
1. |Problem, |intervention, |evaluation |(PIE)system |
2. |Electronic |medical |record |
3. |Problem-oriented |medical |record |
4. |Narrative |system |- |correct |answer |-2
,The |electronic |medical |record |decreases |errors |and |allows |for |the |reconciliation |of |the |patient's |
medications |on |admission, |daily, |and |on |discharge.
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
|- |correct |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 |- |correct |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 |- |correct |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." |- |correct |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. |
