HESI MODULE 5 – Exam
1.ID: 21580633780
A case manager is reviewing progress notes in a client’s medical record. Which notation
indicates the need for follow-up?
S. No Client Condition Notation
Client 1 Five milliliters of bloody drainage was emptied from the
1. Status post–mastectomy:18 hours Jackson-Pratt drain.
Client 2 Crackles were heard in the lower lung lobes bilaterally
2. Heart Failure on auscultation.
Client 3
Status post–appendectomy: 24
3. hours The surgical dressing is clean and dry.
Client 4
4. Diabetes mellitus Blood glucose level is 124 mg/dL (6.9 mmol/L).
A. 1
B. 2 Correct
C. 3
D. 4
Rationale: Crackles heard in the lower lobes of the lungs in a client with heart failure are an
unexpected and unwanted outcome requiring follow-up because they could indicate the
development of pulmonary edema. A case manager is a nurse who assumes responsibility for
coordinating a client's care from the point of admission through, and after, discharge. This nurse
initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care,
evaluating and updating the plan of care as needed. The case manager monitors the client for
expected and unexpected outcomes and provides follow-up and revises the plan of care if an
unexpected outcome is noted. The notations made for the other clients listed represent expected
outcomes.
Test-Taking Strategy: Think about the role of the case manager and read each notation carefully.
Next, focus on the subject, and the strategic words the “need for follow-up”. This will direct
you to the notation that represents an unexpected or unwanted outcome. Crackles heard in the
lower lobes of the lungs on auscultation are a matter of concern.
Review: Heart failure
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Caregiving
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking,
Collaboration/Managing Care
Awarded 96.0 points out of 96.0 possible points.
2.ID: 21580634773
A nurse is planning the client assignments for the shift. Which client is most appropriate for the
nurse to assign to the nursing assistant?
, A. A client with angina who needs to be ambulated for the first time since
admission
B. A client with diarrhea on whom contact precautions have been imposed Correct
C. A client who needs a blood transfusion
D. A client with a draining abdominal wound that requires frequent dressing
changes
Rationale: A client under contact precautions is the most appropriate assignment for the nursing
assistant because the nursing assistant is trained to provide hygiene care and to care for clients
under specific precautions. Assignment of tasks must be based on the job description of the nursing
assistant, the assistant’s level of clinical competence, and state law. Blood transfusions, dressing
changes, and ambulation of a client with angina require the skill of a licensed nurse.
Test-Taking Strategy: Focus on the subject, assigning a client to the nursing assistant. Note
the strategic words “most appropriate”. This indicates the best client to assign to the nursing
assistant. Think about knowledge regarding tasks that may be safely delegated to the nursing
assistant. Read each client description and think about the needs of the client. Recalling that clients
requiring invasive procedures or close monitoring must be assigned to a licensed nurse will assist
you in answering correctly.
Review: delegation and assignment-making
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Clinical Judgemnt, Caregiving
HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-
ClinicalJudgment-Critical thinking
Awarded 96.0 points out of 96.0 possible points.
3.ID: 21580633720
A nurse manager arrives at work and is immediately faced with several activities that require
attention. Which activity will the nurse manager attend to first?
A. Stocking the medication closet
B. Client assignments for the day Correct
C. A phone message from employee health services
D. A phone message from a client’s wife
Rationale: The nurse manager must attend to client assignments first, because client care is the
priority. Also, the nursing staff need their assignments so that they may begin client assessments
and start delivering client care. The nurse manager should next check the medication supply to
ensure that needed medications are available. The nurse manager could also delegate this task to
another registered nurse while client assignments are being planned. The nurse manager would
next return the phone calls.
Test-Taking Strategy: Focus on the subject, activity the nurse manager attends to first. Note
the strategic word “first” and and prioritization skills. Remember that the client is the priority.
Eliminate the options that are not directly related to immediate client needs. This will direct you to the
correct option.
Review: time management
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
, Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Leadership
HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-Clinical
Judgment-Critical Thinking
Awarded 96.0 points out of 96.0 possible points.
4.ID: 21580633717
A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch
breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is
the most appropriate way for the nurse manager to deal with this situation?
A. Confronting the nurse to discuss the behavior and initiate problem-solving
measures Correct
B. Documenting the problem in the nurse’s personnel file
C. Ignoring the situation
D. Asking other staff members to cover for the nurse
Rationale: The nurse manager must confront the nurse, discuss the behavior, and initiate problem-
solving measures to ensure that the behavior does not continue. Taking extended lunch breaks is an
unacceptable behavior, mainly because the behavior affects client care. Ignoring the situation,
asking other staff members to cover for the nurse, and documenting the problem in the nurse’s
personnel file are all inappropriate because none of these actions will resolve the problem.
Test-Taking Strategy: Focus on the subject, dealing with staff member taking extended meal
breaks. Note the stratgegic words “most appropriate”. This indicates the best way to deal with the
situation. Remember your knowledge of the principles of dealing with conflict and unacceptable
behavior and that it is most appropriate to confront and address a problem when it occurs. Also note
that the incorrect options are comparable or alike in that they avoid the problem.
Review: conflict
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Giddens Concepts: Professional Identity, Communication
HESI Concepts: Communication, Clinical Decision Making-Clinical Judgment-Critical Thinking
Awarded 96.0 points out of 96.0 possible points.
5.ID: 21580633244
An emergency department nurse is performing an assessment of a client who has sustained
circumferential burns of both legs. What should the nurse assess first?
A. Radial pulse rate
B. Peripheral pulses Correct
C. Blood pressure (BP)
D. Heart rate
Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered
peripheral circulation. The first or priority assessment is for the nure to check the peripheral pulses
to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the
priority with a circumferential extremity burn is the assessment of peripheral pulses.
Test-Taking Strategy: Focus on the subject, the nurse’s first assessment on a client with a
circumferential burns to the extremities. Eliminate the options that are comparable or alike first
1.ID: 21580633780
A case manager is reviewing progress notes in a client’s medical record. Which notation
indicates the need for follow-up?
S. No Client Condition Notation
Client 1 Five milliliters of bloody drainage was emptied from the
1. Status post–mastectomy:18 hours Jackson-Pratt drain.
Client 2 Crackles were heard in the lower lung lobes bilaterally
2. Heart Failure on auscultation.
Client 3
Status post–appendectomy: 24
3. hours The surgical dressing is clean and dry.
Client 4
4. Diabetes mellitus Blood glucose level is 124 mg/dL (6.9 mmol/L).
A. 1
B. 2 Correct
C. 3
D. 4
Rationale: Crackles heard in the lower lobes of the lungs in a client with heart failure are an
unexpected and unwanted outcome requiring follow-up because they could indicate the
development of pulmonary edema. A case manager is a nurse who assumes responsibility for
coordinating a client's care from the point of admission through, and after, discharge. This nurse
initiates a nursing plan of care, care map, or clinical pathway as appropriate to guide care,
evaluating and updating the plan of care as needed. The case manager monitors the client for
expected and unexpected outcomes and provides follow-up and revises the plan of care if an
unexpected outcome is noted. The notations made for the other clients listed represent expected
outcomes.
Test-Taking Strategy: Think about the role of the case manager and read each notation carefully.
Next, focus on the subject, and the strategic words the “need for follow-up”. This will direct
you to the notation that represents an unexpected or unwanted outcome. Crackles heard in the
lower lobes of the lungs on auscultation are a matter of concern.
Review: Heart failure
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Caregiving
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking,
Collaboration/Managing Care
Awarded 96.0 points out of 96.0 possible points.
2.ID: 21580634773
A nurse is planning the client assignments for the shift. Which client is most appropriate for the
nurse to assign to the nursing assistant?
, A. A client with angina who needs to be ambulated for the first time since
admission
B. A client with diarrhea on whom contact precautions have been imposed Correct
C. A client who needs a blood transfusion
D. A client with a draining abdominal wound that requires frequent dressing
changes
Rationale: A client under contact precautions is the most appropriate assignment for the nursing
assistant because the nursing assistant is trained to provide hygiene care and to care for clients
under specific precautions. Assignment of tasks must be based on the job description of the nursing
assistant, the assistant’s level of clinical competence, and state law. Blood transfusions, dressing
changes, and ambulation of a client with angina require the skill of a licensed nurse.
Test-Taking Strategy: Focus on the subject, assigning a client to the nursing assistant. Note
the strategic words “most appropriate”. This indicates the best client to assign to the nursing
assistant. Think about knowledge regarding tasks that may be safely delegated to the nursing
assistant. Read each client description and think about the needs of the client. Recalling that clients
requiring invasive procedures or close monitoring must be assigned to a licensed nurse will assist
you in answering correctly.
Review: delegation and assignment-making
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Giddens Concepts: Clinical Judgemnt, Caregiving
HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-
ClinicalJudgment-Critical thinking
Awarded 96.0 points out of 96.0 possible points.
3.ID: 21580633720
A nurse manager arrives at work and is immediately faced with several activities that require
attention. Which activity will the nurse manager attend to first?
A. Stocking the medication closet
B. Client assignments for the day Correct
C. A phone message from employee health services
D. A phone message from a client’s wife
Rationale: The nurse manager must attend to client assignments first, because client care is the
priority. Also, the nursing staff need their assignments so that they may begin client assessments
and start delivering client care. The nurse manager should next check the medication supply to
ensure that needed medications are available. The nurse manager could also delegate this task to
another registered nurse while client assignments are being planned. The nurse manager would
next return the phone calls.
Test-Taking Strategy: Focus on the subject, activity the nurse manager attends to first. Note
the strategic word “first” and and prioritization skills. Remember that the client is the priority.
Eliminate the options that are not directly related to immediate client needs. This will direct you to the
correct option.
Review: time management
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
, Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Leadership
HESI Concepts: Professional Behaviors-Professionalism, Clinical Decision Malong-Clinical
Judgment-Critical Thinking
Awarded 96.0 points out of 96.0 possible points.
4.ID: 21580633717
A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch
breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is
the most appropriate way for the nurse manager to deal with this situation?
A. Confronting the nurse to discuss the behavior and initiate problem-solving
measures Correct
B. Documenting the problem in the nurse’s personnel file
C. Ignoring the situation
D. Asking other staff members to cover for the nurse
Rationale: The nurse manager must confront the nurse, discuss the behavior, and initiate problem-
solving measures to ensure that the behavior does not continue. Taking extended lunch breaks is an
unacceptable behavior, mainly because the behavior affects client care. Ignoring the situation,
asking other staff members to cover for the nurse, and documenting the problem in the nurse’s
personnel file are all inappropriate because none of these actions will resolve the problem.
Test-Taking Strategy: Focus on the subject, dealing with staff member taking extended meal
breaks. Note the stratgegic words “most appropriate”. This indicates the best way to deal with the
situation. Remember your knowledge of the principles of dealing with conflict and unacceptable
behavior and that it is most appropriate to confront and address a problem when it occurs. Also note
that the incorrect options are comparable or alike in that they avoid the problem.
Review: conflict
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Giddens Concepts: Professional Identity, Communication
HESI Concepts: Communication, Clinical Decision Making-Clinical Judgment-Critical Thinking
Awarded 96.0 points out of 96.0 possible points.
5.ID: 21580633244
An emergency department nurse is performing an assessment of a client who has sustained
circumferential burns of both legs. What should the nurse assess first?
A. Radial pulse rate
B. Peripheral pulses Correct
C. Blood pressure (BP)
D. Heart rate
Rationale: The client who has sustained circumferential burns to the extremities is at risk for altered
peripheral circulation. The first or priority assessment is for the nure to check the peripheral pulses
to ensure that circulation is adequate. Although the heart rate and BP would also be assessed, the
priority with a circumferential extremity burn is the assessment of peripheral pulses.
Test-Taking Strategy: Focus on the subject, the nurse’s first assessment on a client with a
circumferential burns to the extremities. Eliminate the options that are comparable or alike first
