2022/2023 Module 5 Exam_ HESI VN Questions/Answers

7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 1 1 / 1 pts A client with leukemia is being considered for a bone marrow transplant. The health care 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 health care ethics is the team practicing? Justice Fidelity Autonomy Correct! Nonmaleficence Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in health care ethics, ethical practice involves not only the will to do good but also the equal commitment to do no harm. Health care professionals try to balance the risks and benefits of a plan of care while striving to do the least possible harm. Justice refers to fairness and equity and ensuring fair allocation of resources, such as nursing care for all clients. Fidelity is the keeping of promises made to clients, families, and other health care professionals. Autonomy refers to a person’s independence and represents an agreement to respect another’s right to determine his or her course of action. Test-Taking Strategy: Use knowledge of the subject to help you with the process of elimination. Think about the definition of each item in the options. Note the relationship of the words “least possible harm” in the question and the definition of nonmaleficence. Review the principles of health care ethics 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 2 1 / 1 pts 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. Correct! The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Beneficence is taking action to help others. Although administration of a child’s immunization might cause discomfort, the benefits of protection from disease outweigh the temporary discomfort. Fidelity is keeping promises made to clients, families, and other health care professionals. Autonomy is a person’s independence. Respecting another’s autonomy means that you are agreeing to respect that person’s right to determine his or her course of action. Justice refers to fairness and equity, including fair allocation of resources, such as nursing care for all clients. Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence refers to taking action to help others will direct you to the correct option. Review the principles of health care ethics 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 The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? Performing a procedure without consent Correct! Telling the client that he or she may not leave the hospital Threatening to give a client a medication against his or her will Observing the provision of care to the client without the client’s permission 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Telling a client that he or she may not leave the hospital constitutes false imprisonment. Performing a procedure without consent is an example of battery. Threatening to give a client a medication against his or her will is assault. Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Observing the provision of care to a client without the client’s permission is an example of invasion of privacy. Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note the relationship of the subject and the words in the correct option. If you had difficulty with this question, review the concept of false imprisonment. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal Question 4 1 / 1 pts A nurse and a nursing assistant enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? Ask the nursing assistant to complete an incident report Correct! Check the client s level of consciousness and vital signs Ask the nursing assistant to assist in getting the client back to bed Contact the unit secretary on the intercom and ask that the client’s health care provider be called 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When a client sustains a fall, the nurse must first assess the client. The nurse should check the client’s level of consciousness and vital signs and look for any bruises or injuries sustained in the fall. If the nurse determines that the client has not sustained any injuries and that it is safe to move the client, the nurse should ask the nursing assistant to assist in getting the client into bed. The nurse should then contact the health care provider and file an incident report. Test-Taking Strategy: Note the strategic word “first.” Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment. Remember to always assess the client first if a client sustains a fall. Review client injuries and procedures for 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: Delegating/Prioritizing Question 5 1 / 1 pts Which action exemplifies the use of evidence-based practice in the delivery of client care? Donning sterile gloves to change an abdominal wound dressing Correct! Encouraging a client to take an herbal substance to treat his insomnia Advising a client to agree to the treatment recommended by her health care provider 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Taking a rectal temperature from a client for whom bleeding precautions have been instituted Rationale: Evidence-based practice is an approach to client care in which the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing reflects evidencebased practice because it prevents the entrance of harmful bacteria into the wound. The remaining options do not reflect evidence-based practice. Taking an herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment. Because of the risk of injury to the rectal mucosa, rectal temperature-taking is avoided in the client for whom bleeding precautions have been instituted. Test-Taking Strategy: Read each option carefully, focusing on the subject, evidence-based practice. Recall the definition of evidence-based practice and note the words “sterile gloves” in the correct option. Review the situations that reflect evidence-based practice if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Ques 1 / 1 pts tion 6 The nurse is working with the registered nurse who has accepted a new position as case manager in a hospital. The nurse realizes which responsibilities are part of the registered nurse’s new role? Select all that apply. Correct! Evaluating and updating the plan of care as needed Prescribing treatments specific to the client s needs 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Assessing the client s needs for home supplies and equipment Correct! Correct! Coordinating consultations and referrals to facilitate discharge Establishing a safe and cost-effective plan of care with the client Correct! Rationale: A case manager is a nurse who assumes responsibility for coordinating the client’s care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review the responsibilities of the case manager if you have difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 7 1 / 1 pts 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct! 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “lookingback,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Question 8 1 / 1 pts 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. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Ask the client for permission to lock the necklace in the hospital safe. Correct! Ask the client to remove the necklace and place it in the top drawer of the bedside table. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure. Rationale: When a client has valuables, the nurse should give them to a family member or secure them for safekeeping. Most health care institutions require that a client sign a release form that frees the institution of responsibility if a valuable item (e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace. Valuables may be locked in a designated location such as the hospital’s safe. Removing the necklace and putting it in a drawer does not safeguard it. Asking the client whether the necklace is gold is inappropriate and unrelated to the subject. Test-Taking Strategy: Use the process of elimination and focus on the subject, safeguarding the client’s necklace. Focusing on the subject and noting the word “lock” in the correct option will help you answer correctly. Review the procedures for safeguarding a client’s valuables 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 9 1 / 1 pts A nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) that the client is wearing a wedding band on her left ring finger. The nurse should take which action? Tape the wedding band in place. Correct! Explain to the client why the wedding band must be removed. Ask the client whether she would like to remove the wedding band or wear it to surgery. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery. Rationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a health care facility, the client is asked to sign a form that frees the agency from responsibility if a client’s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client to remove the wedding band and explain why. Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the comparable or alike options that indicate that the client may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review preoperative procedures for a client’s valuables if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Perioperative Care 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 10 1 / 1 pts A nurse preparing a client to go to the radiology department for a neck 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 Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct! Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: A client undergoing a neck x-ray must remove all metal objects to help prevent artifacts on the x-ray. If the client expresses concern about removing the medal, the nurse should help the client pin the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. The nurse should also alert staff in the radiology department that this has been done. If the client is expressing concern about removing the medal, asking the client to remove it or leave it with the nurse or in the bedside stand is inappropriate. Each of these actions also increases the likelihood that the medal and chain will be lost. Test-Taking Strategy: Use the process of elimination and note that the client is expressing concern about removing the religious medal. Eliminate the comparable or alike options that indicate that the client should remove the medal. Also note that the correct option is the only option that addresses the client’s concern. Review care of clients’ valuables if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Safety Question 11 1 / 1 pts A health care provider 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 health care provider, 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? Correct! Contacting the nursing supervisor Continuing to transcribe the prescription 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Asking the nurse assigned to care for the client to administer the medication Verifying the prescribed dose with the client before administering the medication Rationale: A nurse must follow a health care provider’s prescription unless he or she believes that the prescription is in error or that it would harm the client. If a prescription is found to be incorrect or harmful, further clarification from the health care provider is necessary. If the health care provider confirms the prescription and the nurse still believes that it is inappropriate, the nurse should contact the nursing supervisor. The nurse should not continue transcribing the prescription or ask another nurse to implement the prescription. The nurse might ask the client about the medication and the dose taken at home but would not administer the medication. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the medication would be administered. Review the nurse’s responsibilities in regard to a health care provider’s prescriptions 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 12 1 / 1 pts 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 health care provider. The health care provider 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. Which action should the nurse take first? 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Call the nursing supervisor. Explain the procedure to the client, then remove the chest tube. Inform the health care provider that removal of a chest tube is not a nursing procedure. Correct! Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube. Rationale: Actual removal of a chest tube is the duty of a health care provider. Therefore the nurse would first inform the health care provider that this is not a nursing procedure. If the health care provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies’ policies and procedures may permit an advanced practice nurse (a nurse with a master’s degree in a specialized area of nursing) to remove a chest tube. However, there is no information in the question to indicate that the nurse is an advanced practice nurse. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the nurse would remove the chest tube. To select from the remaining options, note the strategic word “first.” The nurse should discuss the prescription with the health care provider. Review nursing responsibilities with regard to removal of a chest tube and standards of care 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 13 1 / 1 pts 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, 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 health care provider who gave the telephone prescription to clarify the prescription Correct! Calling the nursing supervisor for assistance in determining the route of administration Administering the medication intravenously because this route is generally used for clients with CHF Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Telephone prescriptions involve a health care provider’s dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating the prescription clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider’s prescription sheet or enters it into the electronic medical record. Under no circumstances should the nurse try to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. The nurse must call the health care provider who gave the telephone prescription and clarify the prescription. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the nurse should administer the medication without clarifying the health care provider’s prescription. Review the procedures for accepting telephone prescriptions 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 14 1 / 1 pts A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider 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 most appropriate nursing action in this situation? Calling the nursing supervisor to obtain permission to accept the verbal prescription Changing the solution and rate of the IV fluid per the health care provider’s verbal prescription 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Asking the health care provider to write the prescription in the client’s record before leaving the nursing unit Correct! Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record Rationale: The health care provider should write all prescriptions. Verbal prescriptions are not recommended because they increase the risk for error. If a verbal prescription is necessary, such as during an emergency, it should be written and signed by the health care provider as soon as possible, usually within 24 hours. The nurse must follow agency policies and procedures regarding verbal prescriptions. The appropriate nursing action would be to ask the health care provider to write the prescription in the client’s record before leaving the nursing unit. Changing the solution in keeping with the verbal prescription and contacting the supervisor to obtain permission to accept the verbal prescription each imply that the nurse accepts the verbal prescription. Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record delays necessary treatment. Test-Taking Strategy: Use the process of elimination and note the strategic words “most appropriate.” Eliminate the comparable or alike options that imply acceptance of the verbal prescription by the nurse. To select from the remaining options, recall the guidelines and principles for implementing health care provider prescriptions. This will direct you to the correct option. Review nursing responsibilities related to verbal prescriptions 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 15 1 / 1 pts 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) 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 undertaking which action? Reassuring the client that the risks are minimal Calling the surgeon and asking that the risks be explained to the client Correct! Noting in the client’s record that the client was not told about the risks of the surgery Writing a note on the front of the client’s record so that the surgeon will see it when the client arrives in the operating room Rationale: A nurse serves as a client advocate by protecting the right of the client to be informed and to participate in decisions regarding care. The only option that ensures that the client will be informed of the risks of the surgery is contacting the surgeon and asking that the risks be explained to the client. Telling the client that the risks are minimal is false reassurance. Putting a note on the client’s chart or documenting that the client was not informed about the risks does ensure that the client will be informed. Test-Taking Strategy: Use the process of elimination and guidelines and principles of obtaining informed consent. Focusing on the data in the question, the words “never told about the risks of the surgery,” will direct you to the correct option, the only option that ensures that the client will be told about the risks. Review the role of a nurse as a client advocate 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 16 1 / 1 pts 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 statement accurately describes the nurse’s response to the client? The nurse could be charged with battery. Correct! The nurse could be charged with assault. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the health care provider. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client’s consent, the nurse may be charged with assault. Therefore the nurse is not justified in administering the medication. Battery is any intentional touching without the client’s consent. Test-Taking Strategy: Focus on the data in the question and the nurse’s statement. Note that the nurse threatens the client. Next, recall the definition of assault, which will direct you to the correct option. Review violations of client rights 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 17 1 / 1 pts 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. Which is the most appropriate action for the nurse to take? Contact the client’s health care provider. Correct! Report the incident to the nursing supervisor. Tell the client that the nurse did the right thing in giving the enema. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: Battery is any intentional touching of a client without the client’s consent. Such contact may be harmful to the client, or it may merely be offensive to the client’s dignity. If a nurse discovers that battery of a client has occurred, the nurse should report the situation to the nursing supervisor. Telling the client that the nurse did the right thing in giving the enema is incorrect because the other nurse has violated the client’s rights. Confronting the nurse and telling her that she is going to be charged with battery would likely result in unnecessary conflict. Although the health care provider may need to be notified, the nurse should first report the situation to the nursing supervisor. Test-Taking Strategy: Use the process of elimination, and note the strategic words “most appropriate.” Next, focus on the subject, client rights. Recalling that any situation that constitutes a violation of a client’s rights needs to be reported and remembering the organizational channels of reporting will direct you to the correct option. Review the issues surrounding violation of client rights and nursing responsibilities when a client’s rights have been violated 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 18 1 / 1 pts A nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider 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 health care provider was called to clarify the prescription for morphine sulfate. Correct! 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The health care provider made an error in the written prescription for morphine sulfate. The health care provider was called to correct an error in the dosage of morphine sulfate. An incorrect dosage of morphine sulfate was prescribed and the health care provider was notified. Rationale: The nurse needs to document a factual, descriptive, and objective statement that does not include words indicating that an individual made an error or performed an incorrect action or procedure. If a health care provider’s prescription must be questioned, the nurse should record that clarification regarding the prescription was sought. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that indicate that the health care provider made an error in writing a prescription. These options contain the words “error” or “incorrect.” Review the principles of documentation 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 19 1 / 1 pts A nurse at the long-term care unit on the 11 p.m. to 7 a.m. shift is gathering the nursing staff together to listen to the 3 to 11 p.m. intershift report. The nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which action is most appropriate for the nurse to take? 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Contact the nursing supervisor. Ask the staff member how much alcohol she has consumed. Tell the staff member that she is not allowed to administer medications. Ask the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When a staff member reports to work in a state of alcohol intoxication, the nurse notes the signs objectively and asks a second person to validate these observations. The nurse also contacts the nursing supervisor. An odor of alcohol, slurred speech, unsteady gait, and errors in judgment are symptoms of intoxication. Client safety is the primary concern. The intoxicated nurse is removed from the situation. The incident is recorded and the nurse describes the observations, states the action taken, indicates future plans, and has the staff member sign and date the memo of the recorded incident. Refusal to sign and date the memo should be noted by the nurse and a witness. Neither asking the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off nor telling the staff member that he or she will not be allowed to administer medications removes the staff member from the client care area, jeopardizing client safety. Asking the staff member how much alcohol she has consumed is confrontational and irrelevant. Test-Taking Strategy: Use the process of elimination, keeping in mind that client safety is the priority. Asking the staff member how much alcohol she has consumed is irrelevant, so eliminate this option. Next eliminate the comparable or alike options that do not involve removal of the staff member from the client care area. Review nursing responsibilities when substance abuse is suspected in a staff member if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Question 20 1 / 1 pts A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information? That anatomic gifts must be made in writing and signed by the client Correct! 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) To speak with the chaplain about the psychosocial aspects of becoming a donor That this decision must be made by the next of kin at the time of the client’s death To let the health care provider know about the request so that it may be documented in the client’s record Rationale: An individual who is at least 18 years old may make an anatomic gift of all or part of the human body. The gift must be made in writing and signed by the donor. If the client cannot sign, the document must be signed by another individual and two witnesses. The health care provider is informed of the client’s wishes, and the client may wish to speak to a chaplain, but the specific procedure requires a written document that is signed by the client. The family of a deceased client may be asked about organ donation, but this is not the procedure when a living person wishes to become a donor. Test-Taking Strategy: Use the process of elimination, and focus on the subject, a client requesting information about organ donation. Eliminate the option using the closedended word “must.” To select from the remaining options, remember that an anatomic gift must be made in writing and signed by the client. Review the procedure for organ donation 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 21 1 / 1 pts A nurse enters a client’s room to administer a medication that has been prescribed by the health care provider. The client asks the 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) nurse about the medication. Which response by the nurse is appropriate? “It’s to help get rid of the swelling in your feet.” “You need to discuss this medication with your health care provider.” “I know that it’s for fluid buildup, and I think you’ve taken it before.” “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.” Correct! Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Therefore the appropriate response is the one that is thorough and complete. Referring the client to the health care provider places the client’s question on hold. The remaining options are incomplete. Test-Taking Strategy: Note the strategic word “appropriate.” Eliminate the option that refers the client to the health care provider because it places the client’s question on hold. To select from the remaining choices, find the option that is most complete and thorough. Review client rights in regard to the provision of information about medication if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Content Area: Ethical/Legal 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 22 1 / 1 pts A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse. Which action by the nurse is appropriate? Correct! Telling the nursing student to allow the client to rest Telling the nursing student to give the client the bath anyway Telling the client that the health care provider will be informed of the refusal of care Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Rationale: The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client’s decision. Therefore the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate and represent violations of the client’s rights. Telling the client that the health care provider will be informed of the refusal of care is a threatening action on the nurse’s part. Test-Taking Strategy: Use knowledge of the subject, client rights. Eliminate the options that present a threat to the client or indicate that the bath will be given regardless of the client’s wishes. Review client rights 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 23 1 / 1 pts A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A bone scan is being performed. Correct! She will have to discuss the prescribed test with the client. The radiology department is not clear as to which test has been prescribed. She can read the client’s medical record to determine what the health care provider prescribed. Rationale: Unless a client consents, a nurse may not disclose confidential information to anyone else. Therefore the appropriate response is to tell the client’s wife that she will have to discuss the test with the client. Likewise, a client’s medical record is confidential and cannot be given to the wife for reading. Telling the client’s wife that the radiology department is unclear as to what test has been prescribed is inappropriate. The nurse must not place the responsibility or accountability for a prescribed test on another department. Test-Taking Strategy: Use the process of elimination. Focusing on the subject, confidentiality, and recalling the issues surrounding confidentiality will direct you to the correct option. Review the issues surrounding confidentiality 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 24 1 / 1 pts A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should take which action? Allow the television crew to videotape the program. Correct! Explain to the television crew that videotaping is not allowed. Ask the television crew to interview the individuals attending the program individually. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization. Rationale: Privacy is a client’s right to be free from unwanted intrusion into his or her private affairs. Videotaping constitutes an invasion of a client’s privacy, and written permission is required from the client for an action such as photographing or videotaping. Therefore the nurse must explain to the television crew that videotaping is not allowed. The other options are incorrect and constitute invasions of client privacy. Test-Taking Strategy: Focus on the subject, client privacy. Eliminate the comparable or alike options that represent invasions of client privacy. Review violations of client privacy 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 25 1 / 1 pts A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? “Oh, really? I didn’t see that!” Correct! “We can’t discuss a client’s medical condition.” “Yes, that’s why we’ve imposed contact precautions.” “Yes, he does, but be sure not to discuss this with anyone else.” Rationale: A client’s medical condition is confidential and should never be discussed with anyone other than the client and the client’s health care provider. Therefore the nurse must tell the unit secretary that the client’s condition is not to be discussed. The statements “Yes, he does, but be sure not to discuss this with anyone else” and “Yes, that’s why we’ve imposed contact precautions” both confirm the client’s disease and are therefore inappropriate. Responding, “Oh, really? I didn’t see that!” promotes further discussion of the client’s condition and is inappropriate. Test-Taking Strategy: Use the process of elimination, and recall the issues surrounding confidentiality. This will help you eliminate the option that promotes further discussion of the client’s condition. Next, eliminate the comparable or alike options that confirm the client’s illness. Review the issues surrounding confidentiality 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 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Question 26 1 / 1 pts A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action? Call the client’s health care provider. Contact the nursing supervisor for directions. Correct! Administer cardiopulmonary resuscitation (CPR). Administer oxygen to the client and call the health care provider. Rationale: CPR is an emergency treatment that is provided without client consent unless a DNR order is part of the client’s record. Calling the nursing supervisor for directions, administering oxygen to the client, and calling the health care provider are all inappropriate actions that would delay necessary treatment. Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike options that delay necessary treatment. Review procedures related to CPR and DNR orders 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 Ques 1 / 1 pts tion 27 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse respond? Telling the health care provider that “slow codes” are not acceptable Correct! Telling the health care provider that the client would probably want to die in peace Telling the health care provider that all of the nurses on the unit agree with this plan Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: The nurse may not violate a family’s request regarding the client’s treatment plan. A “slow code” is not acceptable, and the nurse should state this to the health care provider. The definition of a “slow code” varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are therefore inappropriate. Test-Taking Strategy: Focus on the data in the question— specifically, that the spouse will not grant permission for a DNR order. Recalling the procedures for CPR and the ethical/legal guidelines for a DNR order will direct you to the correct option. Review the nurse’s responsibility regarding DNR orders and standards of care 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 28 1 / 1 pts A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-notresuscitate (DNR) order. The nurse should provide the client with which information? Consent must be obtained from the family. The health care provider makes the final decision about a DNR request. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) The DNR request should be discussed with the health care provider, who will write the order. Correct! Oral consent is sufficient, and the client’s request will be honored by all health care providers. Rationale: A client may request a DNR order after being given the appropriate information by the health care provider. Therefore, if a client requests a DNR order, the nurse should contact the health care provider so that the health care provider may discuss the request with the client. A DNR order should be written, not verbal. The pertinent agency and state guidelines must be followed with regard to when a verbal DNR order is acceptable. Therefore the other options are incorrect. Test-Taking Strategy: Use the process of elimination and your knowledge of the subject, issues related to DNR orders. Eliminate the options that contain the closedended words “must” and “all.” Next, recall that the client has the right to request a DNR order, which will direct you to the correct option from those remaining. Review the issues related to DNR orders 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 29 1 / 1 pts A man who is visiting his wife in a long-term care facility for people with Alzheimer disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) regarding do-not-resuscitate (DNR) orders does the nurse remember? That a DNR order may be written by a client’s health care provider Correct! That everything possible must be done if the client stops breathing That medications only may be given to the client if the client stops breathing That life support measures will have to be implemented if the client stops breathing Rationale: In a situation in which a client has no family members who can provide permission for treatment, the health care provider may write a DNR order if he or she is reasonably and medically certain that resuscitation would be futile. Therefore the other options are inaccurate. Test-Taking Strategy: Focus on the data in the question, and note that the client is terminally ill and has no family members other than a wife who is mentally incompetent. Eliminate the comparable or alike options that indicate that resuscitation measures will be instituted. Next eliminate the option containing the closed-ended word “only.” Review the ethical and legal issues related to DNR orders if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Ques 1 / 1 pts tion 30 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands which information about DNR orders? The DNR order may not be changed once it is in effect The DNR order requires frequent review as specified by state or agency policy Correct! The only people who may change the DNR order are members of the client s immediate family The DNR order, as written on admission, must remain in effect for the duration of the client s hospitalization Rationale: If the client’s condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client’s hospitalization. The client’s request regarding DNR status is the priority. Test-Taking Strategy: Use the process of elimination. Eliminate the options that use the closed-ended words “may not” and “only.” To select from the remaining options, recall that a DNR status may be changed at any time. Review the ethical and legal issues regarding DNR orders if you had difficulty with this question. Cognitive Ability: Understanding Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Ethical/Legal Question 31 1 / 1 pts 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant? Suctioning a client who requires periodic suctioning Performing colostomy irrigation on a client with an ostomy Assisting a client who needs frequent ambulation with a walker Correct! Assessing a client who has undergone an arteriogram and requires close monitoring 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: When a nurse assigns tasks of a client’s care to another staff member, the nurse is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. Noninvasive interventions such as ambulating a client with a walker may be assigned to a nursing assistant. A client who requires suctioning or one who needs a colostomy irrigation should be assigned to a licensed nurse because these staff members can perform certain invasive procedures. The client who has undergone an arteriogram should be assigned to a licensed nurse because these personnel have the knowledge and education to detect changes in the client’s status that require attention. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment to a nursing assistant. Eliminate the comparable or alike options that involve invasive procedures. To select from the remaining options, think about the education that a nursing assistant receives. The nursing assistant is trained to ambulate a client with an assistive device but does not have the knowledge and education to detect changes in a client’s status. Review the guidelines for assignment of tasks if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 32 1 / 1 pts A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN? Feeding a client on bedrest who needs assistance with feeding 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Turning a client who must be turned and repositioned every 2 hours Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments Correct! Assisting a client who is wearing eye patches and requires assistance with hygiene measures Rationale: When a nurse assigns tasks for a client’s care to another staff member, the nurse is responsible for appropriately assigning tasks on the basis of the educational level and competency of the staff member. A client receiving oxygen who requires pulse oximetry monitoring and respiratory treatments should be assigned to the LPN, because this staff member can perform these tasks and is competent to note changes in the client’s condition. Feeding a client, turning and repositioning a client, and assisting with hygiene measures, all noninvasive interventions, may be assigned to a nursing assistant. Test-Taking Strategy: Use the process of elimination, focusing on the subject of the question, assignment of tasks to an LPN. Think about the activities that the LPN is able to perform. Next, eliminate the comparable or alike options that are noninvasive procedures. Review the principles of assigning tasks if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 33 0.5 / 1 pts 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply. Correct! Conducting client rounds before taking the break Taking the break in the staff lounge located on the nursing unit Correct Answer Asking the nursing assistant to administer a medication placed at the client s bedside if the client awakens Asking the nursing assistant to monitor a client s tube feeding and to contact the nurse when the feeding bag is empty Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby Question 34 1 / 1 pts A nurse is providing a change-of-shift report on the assigned clients using an audiotape. Which pieces of information should the nurse include in the report about each assigned client? Select all that apply. Family history Correct! Client needs and priorities of care Correct! Current diagnosis and any secondary diagnoses Correct! Results of laboratory studies conducted that day 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Correct! Client response to treatments implemented that day The steps used to perform the procedure for changing the client’s sterile dressing at the gastrostomy tube site Rationale: A change-of-shift report ensures continuity of care among nurses caring for a client and informs the nurse on the next shift about the client's needs and priorities for care. It may be given written, orally, by audiotape or while the nurses are walking rounds at a client’s bedside. The report should describe the client’s health status, current and secondary diagnoses, results of laboratory or diagnostic studies done that day, and the client’s response to treatments implemented that day. The client’s family history does not need to be described in a change-of shift report, and doing so would take time. If such information is needed by the oncoming nurse, it may be obtained from the client’s medical record. There is no useful reason for describing a routine procedure; this would also take time, and the information is available in the agency procedure manual. Test-Taking Strategy: Focus on the subject, what to include in the change-of-shift report. Read each option carefully and eliminate family history because it is not directly related to the client’s current status. Next eliminate the option that involves describing the steps in performing a procedure because this is routine information. Also note that the correct options are client focused. Review the components of a change-of-shift report if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Communication and Documentation Content Area: Leadership/Management Ques 1 / 1 pts tion 35 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first? Correct! A client scheduled for hemodialysis at 10 a.m. A client scheduled for a nuclear scanning procedure at 10 a.m. A client scheduled for contrast computed tomography (CT) at noon A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 a.m. 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client’s weight and lung sounds. The nurse must also assess the client’s predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 a.m. may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 a.m. may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory, and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload. Review the principles of prioritizing if you had difficulty with this question. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Question 36 1 / 1 pts A nurse has assigned several nursing tasks to staff members. Which is the nurse’s primary responsibility after assigning tasks? Documenting completion of each task 7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39) Assigning any tasks that were not completed to the next nursing shift Allowing each staff member to make judgments when performing the tasks Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Correct! Rationale: The ultimate responsibility for a task lies with the person who assigned it. Therefore it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementation of the tas