Questions
1. 1.ID: 9477027534
A client with leukemia is being considered for a bone marrow transplant. The
healthcare team is discussing the risks and
... [Show More] 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
words “least possible harm” in the question and the definition of
nonmaleficence. Review: principles of healthcare ethics.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p.
314). St. Louis: Mosby.
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 1.0 points out of 1.0 possible points.
2. 2.ID: 9477024200
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. CorrectExtra Credit HESI Module 5
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: the principles of healthcare ethics .
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
314). St. Louis: Mosby.
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 1.0 points out of 1.0 possible points.
3. 3.ID: 9477029451
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: the concept of false imprisonment.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues:Extra Credit HESI Module 5
Trends & management (4th ed., pp. 175, 176). St. Louis: Mosby.
Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th
ed., p. 424).
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 1.0 points out of 1.0 possible points.
4. 4.ID: 9477017756
The nurse and an unlicensed assistive personnel (UAP)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 report
B. 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 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 UAP to assist in getting the client into bed. The nurse
should then contact the 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 injuries and procedures for filing incident reports .
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient–centered collaborative care (6th ed., p. 180). St. Louis:
Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/PrioritizingExtra Credit HESI Module 5
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Awarded 1.0 points out of 1.0 possible points.
5. 5.ID: 9477020809
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 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,
evidence-based practice. Recall the definition of evidence-based practice and
note the words “sterile gloves” in the correct option. Review: the situations that
reflect evidence-based practice .
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., pp.
54-60). St. Louis: Mosby.
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 1.0 points out of 1.0 possible points.
6. 6.ID: 9477020817
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.Extra Credit HESI Module 5
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 word “prescribing” in the incorrect option. It is not within the
role of the nurse to prescribe. Review: the responsibilities of the case manager
if you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p.
21). St. Louis: Mosby.
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 4.0 points out of 4.0 possible points.
7. 7.ID: 9477028765
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?Extra Credit HESI Module 5
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 word “retrospective” in the question and the description in
the correct option. Review: the procedures for quality improvement and
retrospective and concurrent audits if you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
64, 65). St. Louis: Mosby.
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 1.0 points out of 1.0 possible points.
8. 8.ID: 9477022320
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?Extra Credit HESI Module 5
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
procedure
Rationale: 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: the procedures for safeguarding a client’s
valuables .
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p.
1387). St. Louis: Mosby.
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 1.0 points out of 1.0 possible points.
9. 9.ID: 9477017796
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 surgeryExtra Credit HESI Module 5
Rationale: In most situations a wedding band may be taped in place and worn
during a surgical procedure. However, if the possibility exists that the client will
experience swelling of the hand or fingers, the wedding band should be
removed. On admission to a healthcare facility, the client is asked to sign a
form that frees the agency from responsibility if a client’s valuable is lost. After
mastectomy with axillary lymph node dissection, the client is at risk for
lymphedema, which results in swelling of the arm and hand on the affected
side. Therefore the appropriate nursing action is to ask the client to remove the
wedding band and explain why.
Test-Taking Strategy: Focus on the data in the question. Eliminate the options
that are comparable or alike in that they indicate that the client may wear the
wedding band during the surgical procedure. Next, recall the complications
associated with mastectomy, which will direct you to the correct option. Review:
preoperative procedures for a client’s valuables .
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7thed., p.
1387). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Cellular Regulation, Fluid and Electrolyte Balance
HESI Concepts: Cellular Regulation, Fluids and Electrolytes
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 9477014230
The nurse preparing a client to go to the radiology department for a chest x-ray
notes that the client is wearing a religious medal on a chain around the neck.
The client, a Catholic, expresses a concern about removing the medal. What is
the most appropriate action for the nurse to take?
A. Asking the client to remove the medal until the x-ray has been
completed
B. Assisting the client in pinning the medal and chain to the
waistband of the client’s pajama bottoms Correct
C. Asking the client to place the medal in the top drawer of the
bedside stand just before leaving for the radiology department
D. Telling the client that the medal and chain will be kept at the
nurses’ station for safekeeping while the client is undergoing the xray [Show Less]