LPN Med Surg HESI
Questions and Answers
Updated 2026
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? Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back to the
hospital
2. Documentation that the patient was informed that he or she was leaving against medical
advice
3. Documentation that the risks of leaving against medical advice were explained to the
patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed - 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'srecord 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 understandsthe risks of
leaving against 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'srecord is a legal document, so the nurse should never document that he
or she filed an incident report.
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? SATA
1. Documentation istimely
2. Documentation is concise
,3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate - 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 the patient complaint and
should be labeled late entry. Rationale 2: This entry describes the situation fully but is
concise. Rationale 3: The nurse describesfactual 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.
A nurse documents the following in a patient's medical record: "2/1/ , 1500. Patient appears
weak 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 - Answer 4
In general, employers as well as state, federal, and professional standards require
documentation to include initial and ongoing assessments, any change in the patient's
condition, therapies given and patient response, patient teaching, and relevant statements
by the patient.
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. - 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 allowsfor quick and easy retrieval of information.
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 system - Answer 2
The electronic medical record decreases errors and allows for the reconciliation of the
patient's medications on admission, daily, and on discharge.
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 health
care provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene activities
while in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by occupational
therapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical health
status - Answer 2,5 Rationale 1: Teaching the patient about medications prescribed by the
health care provider is an 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 interdependent activity. Rationale 4: Administering medication prescribed by
the health care provider is an example of a dependent activity. Rationale 5: These activities
are included in assessment, which is an independent activity that nurses may perform,
based on their education and skills.
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, but
, recently 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
nursing action, required in the care of this patient, is considered a dependent role function?
1. Requesting that the health care provider order a consult because the patient states that
her dentures no longer fit properly and she has trouble chewing
2. Asking the nursing assistant to demonstrate to the patient how to operate the call system
3. Interviewing the patient to assess whether she needs assistance with getting out of bed
4. Administering the antibiotics prescribed by the health care provider - Answer 4 Rationale
1: Assessing that the patient has a need that requires further assessment by other team
members and communicating that need to the appropriate team member is an example of
an interdependent activity. Rationale 2: This is an independent activity that nurses may
perform or delegate, based on their and the delegate's education and skills. Rationale 3:
Assessment is an independent activity that nurses may perform, based on their education
and skills. Rationale 4: Dependent activities are those prescribed by the health care provider
and carried out by the nurse
When asking a patient if a pain medication provided a few hours ago has been effective, the
nurse is performing which step of the nursing process?
1. Planning
2. Implementation
3. Evaluation
4. Assessment - Answer 3 Rationale 1: Planning consists of prioritizing among the chosen
nursing diagnoses and determining interventions to move the patient to optimal health.
Rationale 2: Implementation isthe actual "doing" step of the nursing process. In this case,
implementation occurred when the medication was administered. Rationale 3: Evaluation
focuses on a patient's behavioral changes and compares them with the criteria stated in the
objectives. It consists of both the patient's status and the effectiveness of the nursing care.
Both must be evaluated continuously, with the care plan modified as needed. Rationale 4:
Assessment comprises examining the patient and identifying cues, collecting and analyzing
data, and reaching conclusions. In this situation, assessment occurred when the nurse
identified that the patient was in pain
The nursing instructor knows that further education is needed when a student makes which
statement?
1. "Assessment precedes nursing diagnosis and outcome identification."
Questions and Answers
Updated 2026
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? Select all that apply.
1. Documentation that the patient was informed that he or she cannot come back to the
hospital
2. Documentation that the patient was informed that he or she was leaving against medical
advice
3. Documentation that the risks of leaving against medical advice were explained to the
patient
4. Documentation of any discharge instructions given to the patient
5. Documentation indicating an incident report has been completed - 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'srecord 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 understandsthe risks of
leaving against 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'srecord is a legal document, so the nurse should never document that he
or she filed an incident report.
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? SATA
1. Documentation istimely
2. Documentation is concise
,3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate - 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 the patient complaint and
should be labeled late entry. Rationale 2: This entry describes the situation fully but is
concise. Rationale 3: The nurse describesfactual 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.
A nurse documents the following in a patient's medical record: "2/1/ , 1500. Patient appears
weak 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 - Answer 4
In general, employers as well as state, federal, and professional standards require
documentation to include initial and ongoing assessments, any change in the patient's
condition, therapies given and patient response, patient teaching, and relevant statements
by the patient.
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. - 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 allowsfor quick and easy retrieval of information.
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 system - Answer 2
The electronic medical record decreases errors and allows for the reconciliation of the
patient's medications on admission, daily, and on discharge.
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 health
care provider has prescribed
2. Talking with the patient about his or her abilities to manage personal hygiene activities
while in the usual state of health at home
3. Incorporating adaptive techniques into nursing care as recommended by occupational
therapy
4. Administering analgesic medication ordered by the health care provider
5. Introducing oneself to, and interviewing, the patient to collect data about physical health
status - Answer 2,5 Rationale 1: Teaching the patient about medications prescribed by the
health care provider is an 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 interdependent activity. Rationale 4: Administering medication prescribed by
the health care provider is an example of a dependent activity. Rationale 5: These activities
are included in assessment, which is an independent activity that nurses may perform,
based on their education and skills.
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, but
, recently 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
nursing action, required in the care of this patient, is considered a dependent role function?
1. Requesting that the health care provider order a consult because the patient states that
her dentures no longer fit properly and she has trouble chewing
2. Asking the nursing assistant to demonstrate to the patient how to operate the call system
3. Interviewing the patient to assess whether she needs assistance with getting out of bed
4. Administering the antibiotics prescribed by the health care provider - Answer 4 Rationale
1: Assessing that the patient has a need that requires further assessment by other team
members and communicating that need to the appropriate team member is an example of
an interdependent activity. Rationale 2: This is an independent activity that nurses may
perform or delegate, based on their and the delegate's education and skills. Rationale 3:
Assessment is an independent activity that nurses may perform, based on their education
and skills. Rationale 4: Dependent activities are those prescribed by the health care provider
and carried out by the nurse
When asking a patient if a pain medication provided a few hours ago has been effective, the
nurse is performing which step of the nursing process?
1. Planning
2. Implementation
3. Evaluation
4. Assessment - Answer 3 Rationale 1: Planning consists of prioritizing among the chosen
nursing diagnoses and determining interventions to move the patient to optimal health.
Rationale 2: Implementation isthe actual "doing" step of the nursing process. In this case,
implementation occurred when the medication was administered. Rationale 3: Evaluation
focuses on a patient's behavioral changes and compares them with the criteria stated in the
objectives. It consists of both the patient's status and the effectiveness of the nursing care.
Both must be evaluated continuously, with the care plan modified as needed. Rationale 4:
Assessment comprises examining the patient and identifying cues, collecting and analyzing
data, and reaching conclusions. In this situation, assessment occurred when the nurse
identified that the patient was in pain
The nursing instructor knows that further education is needed when a student makes which
statement?
1. "Assessment precedes nursing diagnosis and outcome identification."
