HESI PN 2020 MEDSURG -STUDY GUIDE (QUESTIONS,ANSWERS AND RATIONALES)

HESI PN 2020 MEDSURG -STUDY GUIDE (QUESTIONS,ANSWERS AND RATIONALES) 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? 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? 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? A nursing unit has changed its documentation system to documenting by exception. How will this system save time? A hospital is considering changing its documentation system to reduce the number of medication errors. Which system should the hospital investigate? Which nursing activities are examples of independent functions of the nursing role? 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? 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? The nursing instructor knows that further education is needed when a student makes which statement? A 16-year-old patient has been admitted for treatment of presumptive pelvic inflammatory disease. The patient’s hygiene is poor and she reports living “on the street” for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10 scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome statement is appropriate? While assessing a female patient from the Middle East, the nurse observes that the patient makes no eye contact and answers questions by nodding or with only a few words. The nurse’s entry in the patient’s record states that the patient “appears to be frightened.” This isan example of which factor associated with assessment? The patient tells the nurse that everything “tastes funny” since starting a new medication, making eating unpleasant. The nurse has given this medication to other patients and has not heard this complaint from any of them. The nurse checks the drug reference again to learn whether this is a known side effect of the medication and reads that it is. This information may be helpful in making a nursing diagnosis and determining how best to address this problem. Which data from this scenario is considered subjective? Which statement represents a nursing diagnosis? Which statements reflect collaborative problems? The nurse is using critical thinking to better understand a patient. The nurse is working in which part of the nursing process? Which aspect of critical thinking would the nurse use when making a nursing diagnosis? Critical thinking empowers the nurse to recognize important situational cues and respond quickly to adapt interventions, optimizing their effectiveness and the likelihood of a good outcome. What is true about this aspect of critical thinking? The nurse is using the Kardex to plan a patient’s care. What information would the nurse expect to find in this document? According to the Health Insurance Portability and Accountability Act (HIPAA), which persons have legal access to the patient’s health record? During a routine breast examination of a patient, the nurse notes a small amount of nipple discharge. What nursing actions are indicated? During a routine pelvic examination, the nurse instructs the patient to bear down. The nurse explains that this motion makes it easier to assess for which conditions? The nurse is instructing a female patient about changes in sexual functioning that may result from the aging process. Which nursing diagnoses would the nurse incorporate into the plan of care for this patient regarding sexual intercourse? A female patient who is experiencing hot flashes during menopause asks the nurse how long they will last. Which information should the nurse provide? A young adult male asks the nurse about the recommended frequency of testicular self- exams. How should the nurse respond? A 20-year-old female asks the nurse when she should begin having pelvic examinations. Which question should the nurse ask before responding? The patient asks why the nurse is asking questions about her mother’s obstetrical history. Which rationale for this questioning should the nurse provide? Which statement by a patient offers the nurse information about moliminal symptoms? On assessment the nurse notes that a patient’s urinary opening is on the ventral side of the penis. How should the nurse document this finding? Which precautions should the nurse conducting an assessment of the reproductive system take to avoid the cremasteric reflex? During assessment, the nurse notes a third nipple about 4 inches below the patient’s costal margin. What nursing action is indicated? The patient has respiratory difficulty due to changes in anatomic dead space. The nurse plans interventions based on changes in which physiological process? During an assessment, a patient begins to cough. How would the nurse evaluate this finding? A patient is diagnosed with a low iron count. The nurse would be alert for which finding associated with this condition? During the palpation of a patient’s chest for expansion, the nurse notices a decrease in expansion of the right side. This finding is consistent with which condition? The nurse is preparing to auscultate a patient’s lungs. Which breath sounds would the nurse consider abnormal? During a bronchoscopy, the nurse is to initially give 1.5 mg of midazolam hydrochloride (Versed) and another 1.5 mg of Versed in 2 minutes. Based on a concentration of 5 mg/mL, the nurse will draw up a total of mL for the two doses. A patient has these arterial blood gas (ABG) results. In analyzing the data, the nurse recognizes the patient has which condition? The nurse is conducting a health history on a patient with dyspnea. Place the questions in correct sequence. The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle accident. What is the primary rationale for this nursing action? The nurse anticipates that a patient with multiple fractured ribs is at risk for which condition? A patient admitted with probable emphysema is scheduled for diagnostic tests. Which test would assess the patient’s acid-base balance? After auscultating a patient’s chest, the nurse reports the findings to the preceptor. Which statement would indicate the need for immediate reassessment by the preceptor? The nurse is planning a class for unlicensed assistive personnel. Which factors should the nurse describe as causing interference with accurate pulse oximeter readings? The nurse wants to assess the apex of a patient’s right lung. In which location should the nurse place the stethoscope? The nurse knows that the caregiver of a patient with a respiratory illness understands discharge teaching when the caregiver makes which statement? A review of a patient’s medical record reveals that the patient is using accessory muscles to aid breathing. Which muscle groups would the nurse expect to see in use? A patient with pneumonia is experiencing shunt ventilation. The nurse plans care for the patient based on which considerations? The nurse had planned to conduct a patient interview regarding pulmonary history. Which patient behaviors would indicate to the nurse that this interview should be delayed? A patient from Southeast Asia presents to the clinic with complaints of shortness of breath. The patient says, “I tried to coin my wind illness, but it did not work.” Which assessment finding would the nurse expect? The patient says, “I think I am allergic to something in my house. I feel better when I am away for a few days.” What should the nurse suggest? ...........................................CONTINUED DOWNLOAD FOR BEST SCORES