Page |1
HESI
PN MEDICAL SURGICAL
NGN
NEWEST 2025 COMPLETE
QUESTIONS AND VERIFIED
DETAILED ANSWERS WITH
RATIONALES
, Page |2
HESI PN MEDICAL SURGICAL NGN
NEWEST 2025 COMPLETE QUESTIONS
AND VERIFIED DETAILED ANSWERS
WITH RATIONALES
HESI PN MEDICAL SURGICAL NGN
NEWEST 2025 COMPLETE QUESTIONS
AND VERIFIED DETAILED ANSWERS
WITH RATIONALES
A nurse is caring for a client who is postoperative following an
appendectomy. Which of the following information should the nurse
include when documenting in the electronic medical record?
a) Incision healing well
b) Client status unchanged throughout shift
c) Abdominal wound dry, without redness
d) Client received an adequate amount of fluid - CORRECT-ANSWER-C.
Abdominal wound dry, without redness
Rationale:
, Page |3
According to the ANA's Principles for Nursing Documentation,
documentation should be accurate, timely, complete, factual, organized
and compliant. It should also reflect the nursing process and the full
, Page |4
extent of a nurse's professional capabilities. Some of the information
that should be included when documenting in the electronic medical
record are:
The patient's status, needs, problems, goals, interventions and
outcomes
The time and date of each entry
The medication administered, the route, the dosage, and the patient's
response.
The precautions or preventive measures used, such as bed rails.
The patient's refusal of treatment or medication, and the actions
taken3
Any phone calls to the physician, including the message and response.
The incision site, its appearance, any drainage, dressing changes, and
signs of infection.
HESI
PN MEDICAL SURGICAL
NGN
NEWEST 2025 COMPLETE
QUESTIONS AND VERIFIED
DETAILED ANSWERS WITH
RATIONALES
, Page |2
HESI PN MEDICAL SURGICAL NGN
NEWEST 2025 COMPLETE QUESTIONS
AND VERIFIED DETAILED ANSWERS
WITH RATIONALES
HESI PN MEDICAL SURGICAL NGN
NEWEST 2025 COMPLETE QUESTIONS
AND VERIFIED DETAILED ANSWERS
WITH RATIONALES
A nurse is caring for a client who is postoperative following an
appendectomy. Which of the following information should the nurse
include when documenting in the electronic medical record?
a) Incision healing well
b) Client status unchanged throughout shift
c) Abdominal wound dry, without redness
d) Client received an adequate amount of fluid - CORRECT-ANSWER-C.
Abdominal wound dry, without redness
Rationale:
, Page |3
According to the ANA's Principles for Nursing Documentation,
documentation should be accurate, timely, complete, factual, organized
and compliant. It should also reflect the nursing process and the full
, Page |4
extent of a nurse's professional capabilities. Some of the information
that should be included when documenting in the electronic medical
record are:
The patient's status, needs, problems, goals, interventions and
outcomes
The time and date of each entry
The medication administered, the route, the dosage, and the patient's
response.
The precautions or preventive measures used, such as bed rails.
The patient's refusal of treatment or medication, and the actions
taken3
Any phone calls to the physician, including the message and response.
The incision site, its appearance, any drainage, dressing changes, and
signs of infection.
