2020 HESI Medical-SurgicalLPN/PN
Nursing V1
Question 1
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?
1. Documentation that the patient was informed that he or she cannot come back to
thehospital
2. Documentation that the patient was informed that he or she was leaving against
medicaladvice
3. Documentation that the risks of leaving against medical advice were explained to
thepatient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been
completedCorrect 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’s record 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 understands the risks of
leavingagainst 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’s record is a legal document, so the nurse should
neverdocument that he or she filed an incident report.
Question 2
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?
,1. Documentation is timely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and
accurateCorrect 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
thepatient complaint and should be labeled late entry.
Rationale 2: This entry describes the situation fully but is concise.
Rationale 3: The nurse describes factual 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.
Question 3
A nurse documents the following in a patient’s medical record: “2/1/ , 1500. Patient
appearsweak 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
Rationale 1: Documentation should be objective and avoid vague statements that are
subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be
described. The use of the word “appears” is subjective and could be manipulated later
shouldthe treatment or judgment be challenged.
Rationale 2: The nurse has documented that pain medication will be given. This is
documenting in advance.
Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an
abbreviation. “U” should be written out as “unit(s).” If unsure whether the abbreviation is
,correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be
spelled out as “less than.”
Rationale 4: In general, employers as well as state, federal, and professional standards
requiredocumentation to include initial and ongoing assessments, any change in the
patient’s condition, therapies given and patient response, patient teaching, and relevant
statements bythe patient.
Question 4
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 allows for quick and easy retrieval of information.
Question 5
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
systemCorrect
Answer: 2
Rationale 1: The PIE system consists of a list of the patient’s problems, interventions taken
toalleviate the problems, and evaluation of the patient’s response to the interventions. This
system does not have the specific benefit of reducing medication errors.
Rationale 2: The electronic medical record decreases errors and allows for the
reconciliationof the patient’s medications on admission, daily, and on discharge.
, Rationale 3: The five components of the problem-oriented medical record are baseline data,
aproblem list, a plan of care for each problem, multidisciplinary progress notes, and a
discharge summary. This system does not have the specific benefit of reducing medication
errors.
Rationale 4: Narrative documentation does not have the specific benefit of reducing
medication errors.
Question 6
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
healthcare provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene
activitieswhile in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by
occupationaltherapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical
healthstatus
Correct Answer: 2,5
Rationale 1: Teaching the patient about medications prescribed by the health care provider
isan 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
interdependentactivity.
Rationale 4: Administering medication prescribed by the health care provider is an example
ofa dependent activity.
Rationale 5: These activities are included in assessment, which is an independent activity
thatnurses may perform, based on their education and skills.
Question 7
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,
butrecently 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
nursingaction, required in the care of this patient, is considered a dependent role function?
Nursing V1
Question 1
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?
1. Documentation that the patient was informed that he or she cannot come back to
thehospital
2. Documentation that the patient was informed that he or she was leaving against
medicaladvice
3. Documentation that the risks of leaving against medical advice were explained to
thepatient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been
completedCorrect 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’s record 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 understands the risks of
leavingagainst 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’s record is a legal document, so the nurse should
neverdocument that he or she filed an incident report.
Question 2
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?
,1. Documentation is timely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and
accurateCorrect 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
thepatient complaint and should be labeled late entry.
Rationale 2: This entry describes the situation fully but is concise.
Rationale 3: The nurse describes factual 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.
Question 3
A nurse documents the following in a patient’s medical record: “2/1/ , 1500. Patient
appearsweak 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
Rationale 1: Documentation should be objective and avoid vague statements that are
subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be
described. The use of the word “appears” is subjective and could be manipulated later
shouldthe treatment or judgment be challenged.
Rationale 2: The nurse has documented that pain medication will be given. This is
documenting in advance.
Rationale 3: The Joint Commission has designated the inappropriateness of “u” as an
abbreviation. “U” should be written out as “unit(s).” If unsure whether the abbreviation is
,correct, the nurse should spell out the word; “<” can be misinterpreted, so it should be
spelled out as “less than.”
Rationale 4: In general, employers as well as state, federal, and professional standards
requiredocumentation to include initial and ongoing assessments, any change in the
patient’s condition, therapies given and patient response, patient teaching, and relevant
statements bythe patient.
Question 4
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 allows for quick and easy retrieval of information.
Question 5
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
systemCorrect
Answer: 2
Rationale 1: The PIE system consists of a list of the patient’s problems, interventions taken
toalleviate the problems, and evaluation of the patient’s response to the interventions. This
system does not have the specific benefit of reducing medication errors.
Rationale 2: The electronic medical record decreases errors and allows for the
reconciliationof the patient’s medications on admission, daily, and on discharge.
, Rationale 3: The five components of the problem-oriented medical record are baseline data,
aproblem list, a plan of care for each problem, multidisciplinary progress notes, and a
discharge summary. This system does not have the specific benefit of reducing medication
errors.
Rationale 4: Narrative documentation does not have the specific benefit of reducing
medication errors.
Question 6
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
healthcare provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene
activitieswhile in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by
occupationaltherapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical
healthstatus
Correct Answer: 2,5
Rationale 1: Teaching the patient about medications prescribed by the health care provider
isan 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
interdependentactivity.
Rationale 4: Administering medication prescribed by the health care provider is an example
ofa dependent activity.
Rationale 5: These activities are included in assessment, which is an independent activity
thatnurses may perform, based on their education and skills.
Question 7
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,
butrecently 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
nursingaction, required in the care of this patient, is considered a dependent role function?
