Module 5 Exam
1. 1.ID: 22114995478
A client with leukemia is being considered for a bone marrow transplant. The healthcare
team is discussing the risks
... [Show More] and benefits of this treatment and other possible
treatments with the goal of inflicting the least possible harm on the client. Which
principle of healthcare ethics is the team practicing?
A. Justice
B. Fidelity
C. Autonomy
D. Nonmaleficence Correct
Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in
healthcare ethics, ethical practice involves not only the will to do good but also the
equal commitment to do no harm. Healthcare professionals try to balance the risks and
benefits of a plan of care while striving to do the least possible harm. Justice refers to
fairness and equity and ensuring fair allocation of resources, such as nursing care for all
clients. Fidelity is the keeping of promises made to clients, families, and other
healthcare professionals. Autonomy refers to a person’s independence and represents
an agreement to respect another’s right to determine his or her course of action.
Test-Taking Strategy: Focus on the subject - the ethical principle being utilized.
Recall the definition of each item in the options. Note the relationship of the strategic
words “least possible harm“ in the question and the definition of nonmaleficence.
Review: Nonmaleficience
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Giddens Concepts: Celluar Regulation, Ethics
HESI Concepts: Advocacy/Ethical/Legal Issues, Cellular Regulation
Awarded 96.0 points out of 96.0 possible points.
2. 2.ID: 22114995475
Which action by the nurse represents the ethical principle of beneficence?
A. The nurse upholds a client’s decision to refuse chemotherapy for lung
cancer.
B. The nurse follows a plan of care designed to relieve pain in a client with
cancer.
C. The nurse administers an immunization to a child even though it may
cause discomfort. Correct
D. The nurse provides equal amounts of care to all assigned clients on the
basis of illness acuity.
Rationale: Beneficence is taking action to help others. Although administration of a
child’s immunization might cause discomfort, the benefits of protection from disease
outweigh the temporary discomfort. Fidelity is keeping promises made to clients,families, and other healthcare professionals. Autonomy is a person’s independence.
Respecting another’s autonomy means that you are agreeing to respect that person’s
right to determine his or her course of action. Justice refers to fairness and equity,
including fair allocation of resources, such as nursing care for all clients.
Test-Taking Strategy: Focus on the subject, beneficence. Recalling that beneficence
refers to taking action to help others will direct you to the correct option.
Review: Beneficence
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Giddens Concepts: Ethics, Immunity
HESI Concepts: Advocacy/Ethical/Legal Issues, Immunity
Awarded 96.0 points out of 96.0 possible points.
3. 3.ID: 22114995472
The nursing instructor asks a student to name an example of false imprisonment. Which
situation reflects a violation of this client right?
A. Performing a procedure without consent
B. Telling the client that he or she may not leave the hospital Correct
C. Threatening to give a client a medication against his or her will
D. Observing the provision of care to the client without the client’s
permission
Rationale: Telling a client that he or she may not leave the hospital constitutes false
imprisonment. Performing a procedure without consent is an example of battery.
Threatening to give a client a medication against his or her will is assault. Invasion of
privacy takes place with unreasonable intrusion into an individual’s private affairs.
Observing the provision of care to a client without the client’s permission is an example
of invasion of privacy.
Test-Taking Strategy: Focus on the subject, an example of false imprisonment. Note
the relationship of the subject and the words in the correct option.
Review: false imprisonment
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Giddens Concepts: Health Care Law, Leadership
HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care
Law
Awarded 96.0 points out of 96.0 possible points.
4. 4.ID: 22114995469
The nurse and an assistive personnel (AP) enter a client’s room to provide care and find
the client lying on the floor. Which action should the nurse take first?
A. Ask the nursing assistant to complete an incident reportB. Check the client’s level of consciousness and vital signs Correct
C. Ask the nursing assistant to assist in getting the client back to bed
D. Contact the unit secretary on the intercom and ask that the client’s
primary health care provider be called
Rationale: When a client sustains a fall, the nurse must first assess the client. The
nurse should check the client’s level of consciousness and vital signs and look for any
bruises or injuries sustained in the fall. If the nurse determines that the client has not
sustained any injuries and that it is safe to move the client, the nurse should ask the AP
to assist in getting the client into bed. The nurse should then contact the primary health
care provider and file an incident report.
Test-Taking Strategy: Note the strategic word “first.“ Use the steps of the nursing
process to answer the question. The correct option is the only one that addresses
assessment. Remember to always assess the client first if a client sustains a fall.
Review: Client who falls
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Awarded 96.0 points out of 96.0 possible points.
5. 5.ID: 22114995466
Which action exemplifies the use of evidence-based practice in the delivery of client
care?
A. Donning sterile gloves to change an abdominal wound dressing Correct
B. Encouraging a client to take an herbal substance to treat his insomnia
C. Advising a client to agree to the treatment recommended by her primary
health care provider
D. Taking a rectal temperature from a client for whom bleeding precautions
have been instituted
Rationale: Evidence-based practice is an approach to client care in which the nurse
integrates the client’s preferences, clinical expertise, and the best research evidence to
deliver quality care. Donning sterile gloves to change an abdominal wound dressing
reflects evidence-based practice, because it prevents the entrance of harmful bacteria
into the wound. The remaining options do not reflect evidence-based practice. Taking an
herbal substance could be harmful to some clients. It is nontherapeutic for a nurse to
advise a client to agree to a treatment. Because of the risk of injury to the rectal
mucosa, rectal temperature-taking is avoided in the client for whom bleeding
precautions have been instituted.
Test-Taking Strategy: Read each option carefully, focusing on the subject, evidencebased practice. Recall the definition of evidence-based practice and note the strategic
words “sterile gloves“ in the correct option.
Review: evidence-based practiceLevel of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Giddens Concepts: Evidence, Safety
HESI Concepts: Evidence-Based Practice/Evidence, Safety
Awarded 96.0 points out of 96.0 possible points.
6. 6.ID: 22114995463
The registered nurse has accepted a new position as case manager in a hospital. Which
responsibilities are part of the nurse’s new role? Select all that apply.
A. Evaluating and updating the plan of care as needed Correct
B. Prescribing treatments specific to the client’s needs
C. Assessing the client’s needs for home supplies and equipment Correct
D. Coordinating consultations and referrals to facilitate discharge Correct
E. Establishing a safe and cost-effective plan of care with the client Correct
Rationale: A case manager is a nurse who assumes responsibility for coordinating the
client's care from the point of admission through, and after, discharge. Specific
responsibilities of the case manager include establishing a safe and cost-effective plan
of care with the client, coordinating consultations and referrals, and facilitating
discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate
to guide care and evaluating and updating the plan of care as needed; ensuring that the
plan of care is tailored to the client’s needs, taking into account the client’s diagnosis,
self-care ability, and prescribed treatments; assessing the client’s need for equipment
such as oxygen or wound care supplies and exploring available resources to provide the
client with these supplies; providing resources that will assist the client in maintaining
independence as much as possible; and providing the client with information on
discharge procedures and the plan of care. The nurse does not prescribe treatments.
Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager.
Note the strategic word “prescribing“ in the incorrect option. It is not within the role of
the nurse to prescribe.
Review: case management
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Giddens Concepts: Care Coordination, Leadership
HESI Concepts: Collaboration/Managing Care—Care Coordination,
Collaboration/Managing Care–Leadership
Awarded 96.0 points out of 96.0 possible points.
7. 7.ID: 22114995460
The nurse manager of a quality improvement program asks a nurse in the neurological
unit to conduct a retrospective audit. Which action should the auditing nurse plan to
perform in this type of audit?A. Checking the documentation written by a new nursing graduate on her
assigned clients at the end of the shift
B. Checking the crash cart to ensure that all needed supplies are readily
available should an emergency arise
C. Reviewing neurological assessment checklists for all clients on the unit to
ensure that these assessments are being conducted as prescribed
D. Obtaining the assigned medical record from the hospital’s medical record
room to review documentation made during a client’s hospital stay Correct
Rationale: Quality improvement, also known as performance improvement, is focused
on processes or systems that significantly contribute to client safety and effective client
care outcomes. Criteria are used to assess outcomes of care and determine the need for
changes improve the quality of care. In a retrospective, or “looking back,“ audit, the
medical record is inspected after the client’s discharge for documentation of compliance
with standards. In a concurrent, or “at the same time,“ audit, the nursing staff’s
compliance with predetermined standards and criteria is assessed as the nurses are
providing care during the client’s stay. In this type of audit, a peer review approach in
which members of the nursing staff are involved in data collection may be implemented.
Obtaining the a client’s medical record from the medical record room for the purpose of
reviewing documentation made during the client’s hospital stay is an example of a
retrospective audit. The incorrect options are examples of concurrent audits.
Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the
relationship of the strategic word “retrospective“ in the question and the description
in the correct option.
Review: quality improvement and retrospective and concurrent audits
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Giddens Concepts: Health Care Quality, Leadership
HESI Concepts: Collaboration/Managing Care—Leadership, Quality
Improvement/Health Care Quality
Awarded 96.0 points out of 96.0 possible points.
8. 8.ID: 22114995457
The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold
necklace. What should the nurse do to safeguard the client’s necklace?
A. Ask the client whether the necklace is gold
B. Ask the client for permission to lock the necklace in the hospital
safe Correct
C. Ask the client to remove the necklace and place it in the top drawer of the
bedside table
D. Ask the client to sign a release to free the hospital of responsibility if the
necklace is damaged or lost during the procedureRationale: When a client has valuables, the nurse should give them to a family
member or secure them for safekeeping. Most health care institutions require that a
client sign a release form that frees the institution of responsibility if a valuable item
(e.g., jewelry, money) is lost, but this does not safeguard the client’s necklace.
Valuables may be locked in a designated location such as the hospital’s safe. Removing
the necklace and putting it in a drawer does not safeguard it. Asking the client whether
the necklace is gold is inappropriate and unrelated to the subject.
Test-Taking Strategy: Focus on the subject, safeguarding the client’s necklace.
Focusing on the subject and noting the word “lock“ in the correct option will help you
answer correctly.
Review: client’s valuables
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Giddens Concepts: Ethics, Health Care Policy
HESI Concepts: Advocacy/Ethical/Legal Issues, Health Policy/Systems—Health Care
Policy
Awarded 96.0 points out of 96.0 possible points.
9. 9.ID: 22114995415
The nurse providing preoperative care to a client who is scheduled for a left mastectomy
and axillary lymph node dissection notes that the client is wearing a wedding band on
her left ring finger. Which action should the nurse take?
A. Tape the wedding band in place
B. Explain to the client why the wedding band must be removed Correct
C. Ask the client whether she would like to remove the wedding band or
wear it to surgery
D. Ask the client to sign a release to free the hospital of responsibility if the
wedding band is lost during surgery [Show Less]