2020 HESI Medical-Surgical

LPN/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 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

Correct 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 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’s record is a legal document, so the nurse should never

document 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?

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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 accurate

Correct 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 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 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.

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 should

the 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

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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 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.

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 system

Correct Answer: 2

Rationale 1: The PIE system consists of a list of the patient’s problems, interventions taken to

alleviate 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 reconciliation

of the patient’s medications on admission, daily, and on discharge.

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Rationale 3: The five components of the problem-oriented medical record are baseline data, a

problem 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 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

Correct 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.

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, 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?

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