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HESI 101 Module 6 Exam_ HESI VN 2021 With Rationales

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Which event would require a nurse to complete and file an incident report? A client has a seizure. The nurse determines that a client would benefit from the use of a walker to ambulate. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor’s blood pressure and takes the visitor to the emergency department for treatment. Correct! 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. Examples of incidents include client falls, needlestick injuries, a visitor having symptoms of illness, medication administration errors, accidental omission of prescribed therapies, and circumstances leading to injury or a risk for injury. An incident report does not need to be filed if a client has a seizure unless the client sustains injury as a result of the seizure. If the nurse determines that a client would benefit from the use of a walker to ambulate, he or she should take the appropriate action to obtain one. If the nurse notes that the battery of an intravenous infusion pump is not working, he or she should obtain a functioning pump and send the nonfunctioning pump to the appropriate department for repair. Test-Taking Strategy: Use knowledge of the subject, reasons for filing an incident report, to assist you with the process of elimination. Read each option carefully. Recalling that an incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client will direct you to the correct option. Review the reasons for filing an incident report if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 2 1 / 1 pts A nurse, charting the administration of medications to an assigned client at 9 p.m., notes that atenolol (Tenormin) was prescribed to be administered at 9 a.m. instead of 9 p.m. The nurse checks the client’s vital signs, completes an incident report, and calls the health care provider to report the error. The health care provider tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Notifying the nursing supervisor Tearing up and discarding the incident report Telling the health care provider that the error warrants the completion of an incident report Correct! Telling the nursing supervisor that the health care provider did not want an incident report completed and filed Rationale: Incident reports are an important part of a health care agency’s quality improvement program. An incident is any event that is not consistent with the routine operation of a health care unit or routine care of a client. An example of an incident is administering a medication at a time at which it is not prescribed to be given. Whenever an incident occurs, an incident report is completed and filed in accordance with agency guidelines. The nursing supervisor would be notified of the incident; however, on the basis of the data in the question, the nurse should tell the health care provider that the error warrants completion and follow-through with an incident report. Therefore, the other options are incorrect. Test-Taking Strategy: Focus on the subject of the question, the health care provider’s telling the nurse that an incident report is not needed. Eliminate the comparable or alike options that involve notifying the nursing supervisor. To select from the remaining options, recall the purpose of an incident report to select the correct option. Review the procedures involved in completing and filing incident reports if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Ethical/Legal Question 3 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant to take which action? To transfer the client to a semiprivate room That gloves only are needed to care for the client To wear gloves and a gown when changing the client’s bed linen Correct! To wear a gown when caring for the client and remove the gown immediately after leaving the client s room Rationale: Contact precautions require the use of gloves, gown, and goggles if direct client contact is anticipated. The client should be placed in a private room or, if a private room is not available, in a semiprivate room with another client who has active infection with the same microorganism but no other infection. The nursing assistant would remove the protective gear before leaving the client’s room. Test-Taking Strategy: Use the process of elimination. Eliminate the option that includes the closed-ended word “only.” Next eliminate the option that involves removal of the gown after leaving the client’s room. To select from the remaining options, read each carefully and visualize the procedure instituted for contact precautions, which will direct you to the correct option. If you had difficulty with this question, review contact precautions. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Leadership/Management Question 4 1 / 1 pts 7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately take which action? Correct! Call a poison control center. Administer an excessive amount of fluids to induce vomiting. Call an ambulance to bring the child to the emergency department. Leave a message at the health care provider answering service

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7/19/2021 Module I6 IExam: IHESI IVN ITXGRP I1912COHORT(VNE
I39)

Question 1 I
pts
I I I

Which Ievent Iwould Irequire Ia Inurse Ito Icomplete Iand Ifile Ian
Ii ncident Ireport?

A Iclient Ihas Ia Iseizure.

The Inurse Idetermines Ithat Ia Iclient Iwould Ibenefit Ifrom Ithe Iuse Iof
Ia Iwalker Ito Iambulate.

The Inurse, Ipreparing Ian Iintravenous Iinfusion, Inotes Ithat Ithe
Ibattery Iof Ian Iintravenous Iinfusion Ipump Iis Inot Iworking.

Co
orrrec
ct!
When Ia Ivisitor Isuddenly Ibecomes Iweak Iand Idizzy, Ithe Inurse
Ichecks Ithe Ivisitor’s Iblood Ipressure Iand Itakes Ithe Ivisitor Ito Ithe

Iemergency Idepartment Ifor Itreatment.

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,7/19/2021 Module I6 IExam: IHESI IVN ITXGRP I1912COHORT(VNE
I39)

Rationale: IAn Iincident Iis Iany Ievent Ithat Iis Inot Iconsistent
Iwith Ithe Iroutine Ioperation Iof Ia Ihealth Icare Iunit Ior Iroutine

Icare Iof Ia Iclient. IExamples Iof Iincidents Iinclude Iclient Ifalls,

Ineedlestick Iinjuries, Ia Ivisitor Ihaving Isymptoms Iof Iillness,

I medication Iadministration Ierrors, Iaccidental Iomission Iof

Iprescribed Itherapies, Iand Icircumstances Ileading Ito Iinjury

Ior Ia Irisk Ifor Iinjury. IAn Iincident Ireport Idoes Inot Ineed Ito Ibe

Ifiled Iif Ia Iclient Ihas Ia Iseizure Iunless Ithe Iclient Isustains

Iinjury Ias Ia Iresult Iof Ithe Iseizure. IIf Ithe Inurse Idetermines

Ithat Ia Iclient Iwould Ibenefit Ifrom Ithe Iuse Iof Ia Iwalker Ito

Iambulate, Ihe Ior Ishe Ishould Itake Ithe Iappropriate Iaction Ito

Iobtain Ione. IIf Ithe Inurse Inotes Ithat Ithe Ibattery Iof Ian

Iintravenous Iinfusion Ipump Iis Inot Iworking, Ihe Ior Ishe

Ishould Iobtain Ia Ifunctioning Ipump Iand Isend Ithe

Inonfunctioning Ipump Ito Ithe Iappropriate Idepartment Ifor

Irepair.

Test-Taking IStrategy: IUse Iknowledge Iof Ithe Isubject,
Ireasons Ifor Ifiling Ian Iincident Ireport, Ito Iassist Iyou Iwith Ithe

Iprocess Iof Ielimination. IRead Ieach Ioption Icarefully.

Recalling Ithat Ian Iincident Iis Iany Ievent Ithat Iis Inot
Iconsistent Iwith Ithe Iroutine Ioperation Iof Ia Ihealth Icare Iunit

Ior Iroutine Icare Iof Ia Iclient Iwill Idirect Iyou Ito Ithe Icorrect

Ioption. IReview Ithe Ireasons Ifor Ifiling Ian Iincident Ireport Iif

Iyou Ihad Idifficulty Iwith Ithis Iquestion.

Cognitive IAbility: IApplying

Client INeeds: ISafe Iand IEffective ICare IEnvironment

I Integrated IProcess: INursing IProcess/Implementation

Content IArea: IEthical/Legal
I

Question 2 I
pts
I I I

A Inurse, Icharting Ithe Iadministration Iof Imedications Ito Ian Iassigned
Iclient Iat I9 Ip.m., Inotes Ithat Iatenolol I(Tenormin) Iwas Iprescribed Ito

Ibe Iadministered Iat I9 Ia.m. Iinstead Iof I9 Ip.m. IThe Inurse Ichecks Ithe

Iclient’s Ivital Isigns, Icompletes Ian Iincident Ireport,Iand Icalls Ithe

Ihealth Icare Iprovider Ito Ireport Ithe Ierror. IThe Ihealth Icare Iprovider

Itells Ithe Inurse Ithat Ian Iincident Ireport Iis Inot Ineeded Ibut Iinstructs

Iher Ito Imonitor Ithe Iclient Iduring Ithe Inight Ifor Ihypotension. IWhat

Iaction Ishould Ithe Inurse Itake?

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,7/19/2021 Module I6 IExam: IHESI IVN ITXGRP I1912COHORT(VNE
I39)

Notifying Ithe Inursing Isupervisor

Tearing Iup Iand Idiscarding Ithe Iincident Ireport

Co
orrrec
ct!
Telling Ithe Ihealth Icare Iprovider Ithat Ithe Ierror Iwarrants Ithe
Icompletion Iof Ian Iincident Ireport

Telling Ithe Inursing Isupervisor Ithat Ithe Ihealth Icare Iprovider Idid Inot
Iw ant Ian Iincident Ireport Icompleted Iand Ifiled

Rationale: IIncident Ireports Iare Ian Iimportant Ipart Iof Ia Ihealth
Icare Iagency’s Iquality Iimprovement Iprogram. IAn Iincident Iis

Iany Ievent Ithat Iis Inot Iconsistent Iwith Ithe Iroutine Ioperation

Iof Ia Ihealth Icare Iunit Ior Iroutine Icare Iof Ia Iclient. IAn Iexample

Iof Ian Iincident Iis Iadministering Ia Imedication IatIa Itime Iat

Iwhich Iit Iis Inot Iprescribed Ito Ibe Igiven. IWhenever Ian

Iincident Ioccurs, Ian Iincident Ireport Iis Icompleted Iand Ifiled Iin

Iaccordance Iwith Iagency Iguidelines. IThe Inursing

Isupervisor Iwould Ibe Inotified Iof Ithe Iincident; Ihowever, Ion

Ithe Ibasis Iof Ithe Idata Iin Ithe Iquestion, Ithe Inurse Ishould Itell

Ithe Ihealth Icare Iprovider Ithat Ithe Ierror Iwarrants Icompletion

Iand Ifollow-through Iwith Ian Iincident Ireport. ITherefore, Ithe

Iother Ioptions Iare Iincorrect.

Test-Taking IStrategy: IFocus Ion Ithe Isubject Iof Ithe Iquestion,
Ithe Ihealth Icare Iprovider’s Itelling Ithe Inurse Ithat Ian Iincident

Ireport Iis Inot Ineeded. IEliminate Ithe IcomparableIor Ialike

Ioptions Ithat Iinvolve Inotifying Ithe Inursing Isupervisor. ITo

Iselect Ifrom Ithe Iremaining Ioptions, Irecall ItheIpurpose Iof Ian

Iincident Ireport Ito Iselect Ithe Icorrect Ioption.

Review Ithe Iprocedures Iinvolved Iin Icompleting Iand Ifiling
Ii ncident Ireports Iif Iyou Ihad Idifficulty Iwith Ithis Iquestion.

Cognitive IAbility: IApplying

Client INeeds: ISafe Iand IEffective ICare IEnvironment

I Integrated IProcess: INursing IProcess/Implementation

Content IArea: IEthical/Legal
I

Question 3 I
pts
I I I

3/109

, 7/19/2021 Module I6 IExam: IHESI IVN ITXGRP I1912COHORT(VNE
I39)
Contact Iprecautions Iare Iinitiated Ifor Ia Iclient Iwith Imethicillin-
Iresistant IStaphylococcus Iaureus I(MRSA) Iinfection. IThe Inurse,

Iproviding Iinstructions Ito Ia Inursing Iassistant Iabout Icaring Ifor Ithe

Iclient, Itells Ithe Iassistant Ito Itake Iwhich Iaction?

To Itransfer Ithe Iclient Ito Ia Isemiprivate Iroom

That Igloves Ionly Iare Ineeded Ito Icare Ifor Ithe Iclient

Co
orrrec
ct!
To Iwear Igloves Iand Ia Igown Iwhen Ichanging Ithe Iclient’s Ibed Ilinen

To Iwear Ia Igown Iwhen Icaring Ifor Ithe Iclient Iand Iremove Ithe Igown
Iimmediately Iafter Ileaving Ithe Iclient Is Iroom

Rationale: IContact Iprecautions Irequire Ithe Iuse Iof Igloves,
Igown, Iand Igoggles Iif Idirect Iclient Icontact Iis Ianticipated.

IThe Iclient Ishould Ibe Iplaced Iin Ia Iprivate Iroom Ior, Iif Ia

Iprivate Iroom Iis Inot Iavailable, Iin Ia Isemiprivate Iroom I with

Ianother Iclient Iwho Ihas Iactive Iinfection Iwith Ithe Isame

I microorganism Ibut Ino Iother Iinfection. IThe Inursing

Iassistant Iwould Iremove Ithe Iprotective Igear Ibefore Ileaving

Ithe Iclient’s Iroom.

Test-Taking IStrategy: IUse Ithe Iprocess Iof Ielimination.
IEliminate Ithe Ioption Ithat Iincludes Ithe Iclosed-ended Iword

I“only.” INext Ieliminate Ithe Ioption Ithat Iinvolves Iremoval Iof

Ithe Igown Iafter Ileaving Ithe Iclient’s Iroom. ITo Iselect Ifrom Ithe

Iremaining Ioptions, Iread Ieach Icarefully Iand Ivisualize Ithe

Iprocedure Iinstituted Ifor Icontact Iprecautions, Iwhich Iwill

Idirect Iyou Ito Ithe Icorrect Ioption. IIf Iyou Ihad Idifficulty Iwith

Ithis Iquestion, Ireview Icontact Iprecautions.

Cognitive IAbility: IApplying

Client INeeds: ISafe Iand IEffective ICare IEnvironment

Integrated IProcess: ITeaching Iand ILearning

Content IArea: ILeadership/Management

Question 4 I
pts
I I I

4/109

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Vak: HESI 101

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HESI 101 Module 6 Exam_ HESI VN 2021 With Rationales

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