Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 1/117
Question 1 1 /
... [Show More] 1 pts
A client with leukemia is being considered for a bone marrow
transplant. The health care team is discussing the risks and
benefits of this treatment and other possible treatments with the
goal of inflicting the least possible harm on the client. Which
principle of health care ethics is the team practicing?
Justice Fidelity Autonomy
Correct! Nonmaleficence
Rationale: Nonmaleficence is the avoidance of hurt or
harm. Remember that in health care ethics, ethical
practice involves not only the will to do good but also the
equal commitment to do no harm. Health care
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 health care 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: Use knowledge of the subject to
help you with the process of elimination. Think about 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 the principles of
health care ethics if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 2/117
Question 2 1 / 1 pts
Which action by the nurse represents the ethical principle of
beneficence?
The nurse upholds a client’s decision to refuse chemotherapy for
lung cancer.
The nurse follows a plan of care designed to relieve pain in a
client with cancer.
The nurse administers an immunization to a child even though it
may cause discomfort.
Correct!
The nurse provides equal amounts of care to all assigned clients
on the basis of illness acuity.
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 3/117
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 health care
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 health care ethics if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 3 1 / 1 pts
The nursing instructor asks a student to name an example of
false imprisonment. Which situation reflects a violation of this
client right?
Performing a procedure without consent
Correct! Telling the client that he or she may not leave the hospital
Threatening to give a client a medication against his or her will Observing the provision of care to the client without the client’s
permission
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 4/117
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. If you had difficulty
with this question, review the concept of false
imprisonment.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Question 4 1 / 1 pts
A nurse and a nursing assistant enter a client’s room to provide
care and find the client lying on the floor. Which action should the
nurse take first?
Ask the nursing assistant to complete an incident report
Correct! Check the client s level of consciousness and vital signs
Ask the nursing assistant to assist in getting the client back to
bed
Contact the unit secretary on the intercom and ask that the
client’s health care provider be called
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 5/117
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 nursing assistant 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 if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Question 5 1 / 1 pts
Which action exemplifies the use of evidence-based practice in
the delivery of client care?
Donning sterile gloves to change an abdominal wound dressing
Correct!
Encouraging a client to take an herbal substance to treat his
insomnia
Advising a client to agree to the treatment recommended by her
health care provider
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 6/117
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 evidencebased 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 if you had difficulty
with this question.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Ques 1 / 1 pts tion 6
The nurse is working with the registered nurse who has accepted
a new position as case manager in a hospital. The nurse realizes
which responsibilities are part of the registered nurse’s new
role? Select all that apply.
Correct! Evaluating and updating the plan of care as needed Prescribing treatments specific to the client s needs
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 7/117
Assessing the client s needs for home supplies and equipment
Correct!
Correct! Coordinating consultations and referrals to facilitate discharge
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.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Question 7 1 / 1 pts
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 8/117
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?
Checking the documentation written by a new nursing graduate
on her assigned clients at the end of the shift
Checking the crash cart to ensure that all needed supplies are
readily available should an emergency arise
Reviewing neurological assessment checklists for all clients on
the unit to ensure that these assessments are being conducted
as prescribed
Obtaining the assigned medical record from the hospital’s
medical record room to review documentation made during a
client’s hospital stay
Correct!
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 9/117
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 “lookingback,” 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.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Question 8 1 / 1 pts
A 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?
Ask the client whether the necklace is gold.
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 10/117
Ask the client for permission to lock the necklace in the hospital
safe.
Correct!
Ask the client to remove the necklace and place it in the top
drawer of the bedside table.
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: Use the process of elimination and
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 if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 9 1 / 1 pts
A nurse providing preoperative care to a client who is scheduled
for a left mastectomy and axillary lymph node dissection notes
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 11/117
that the client is wearing a wedding band on her left ring finger.
The nurse should take which action?
Tape the wedding band in place.
Correct! Explain to the client why the wedding band must be removed.
Ask the client whether she would like to remove the wedding
band or wear it to surgery.
Ask the client to sign a release to free the hospital of
responsibility if the wedding band is lost during surgery.
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 health care
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: Use the process of elimination and
focus on the data in the question. Eliminate the
comparable or alike options that 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 if
you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 12/117
Question 10 1 / 1 pts
A nurse preparing a client to go to the radiology department for a
neck 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?
Asking the client to remove the medal until the x-ray has been
completed
Assisting the client in pinning the medal and chain to the
waistband of the client’s pajama bottoms
Correct!
Asking the client to place the medal in the top drawer of the
bedside stand just before leaving for the radiology department
Telling the client that the medal and chain will be kept at the
nurses’ station for safekeeping while the client is undergoing the
x-ray
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 13/117
Rationale: A client undergoing a neck x-ray must remove
all metal objects to help prevent artifacts on the x-ray. If
the client expresses concern about removing the medal,
the nurse should help the client pin the medal and chain to
the hospital gown or in another area where it will not
appear on the x-ray image. The nurse should also alert
staff in the radiology department that this has been done.
If the client is expressing concern about removing the
medal, asking the client to remove it or leave it with the
nurse or in the bedside stand is inappropriate. Each of
these actions also increases the likelihood that the medal
and chain will be lost.
Test-Taking Strategy: Use the process of elimination and
note that the client is expressing concern about removing
the religious medal. Eliminate the comparable or alike
options that indicate that the client should remove the
medal. Also note that the correct option is the only option
that addresses the client’s concern. Review care of clients’
valuables if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Question 11 1 / 1 pts
A health care provider writes a medication prescription in a
client’s record. While transcribing the prescription, the nurse
notes that the prescribed dose is three times higher than the
recommended dose. The nurse calls the health care provider,
who states that this is the dose that the client takes at home and
that it is acceptable for this client’s condition. What is the
appropriate action for the nurse to take?
Correct! Contacting the nursing supervisor
Continuing to transcribe the prescription
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 14/117
Asking the nurse assigned to care for the client to administer the
medication
Verifying the prescribed dose with the client before administering
the medication
Rationale: A nurse must follow a health care provider’s
prescription unless he or she believes that the prescription
is in error or that it would harm the client. If a prescription
is found to be incorrect or harmful, further clarification from
the health care provider is necessary. If the health care
provider confirms the prescription and the nurse still
believes that it is inappropriate, the nurse should contact
the nursing supervisor. The nurse should not continue
transcribing the prescription or ask another nurse to
implement the prescription. The nurse might ask the client
about the medication and the dose taken at home but
would not administer the medication.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that indicate that
the medication would be administered. Review the nurse’s
responsibilities in regard to a health care provider’s
prescriptions if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 12 1 / 1 pts
nurse monitoring a client with a chest tube notes that there is no
tidaling of fluid in the water seal chamber. After further
assessment, the nurse suspects that the client’s lung has
reexpanded and notifies the health care provider. The health care
provider verifies with the use of a chest x-ray that the lung has
reexpanded, then calls the nurse to asks that the chest tube be
removed. Which action should the nurse take first?
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 15/117
Call the nursing supervisor.
Explain the procedure to the client, then remove the chest tube.
Inform the health care provider that removal of a chest tube is not
a nursing procedure.
Correct!
Obtain petrolatum-impregnated gauze and ask another nurse to
assist in removing the chest tube.
Rationale: Actual removal of a chest tube is the duty of a
health care provider. Therefore the nurse would first inform
the health care provider that this is not a nursing
procedure. If the health care provider insists that the nurse
remove the tube, the nurse must contact the nursing
supervisor. Some agencies’ policies and procedures may
permit an advanced practice nurse (a nurse with a
master’s degree in a specialized area of nursing) to
remove a chest tube. However, there is no information in
the question to indicate that the nurse is an advanced
practice nurse.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that indicate that
the nurse would remove the chest tube. To select from the
remaining options, note the strategic word “first.” The
nurse should discuss the prescription with the health care
provider. Review nursing responsibilities with regard to
removal of a chest tube and standards of care if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 13 1 / 1 pts
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 16/117
A nurse calls a health care provider to report that a client with
congestive heart failure (CHF) is exhibiting dyspnea and
worsening of wheezing. The health care provider, who is in a
hurry because of a situation in the emergency department, gives
the nurse a telephone prescription for furosemide (Lasix) but
does not specify the route of administration. What is the
appropriate action on the part of the nurse?
Calling the health care provider who gave the telephone
prescription to clarify the prescription
Correct!
Calling the nursing supervisor for assistance in determining the
route of administration
Administering the medication intravenously because this route is
generally used for clients with CHF
Administering the medication orally and clarifying the prescription
once the health care provider has finished caring for the client in
the emergency department
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 17/117
Rationale: Telephone prescriptions involve a health care
provider’s dictating a prescribed therapy over the
telephone to the nurse. The nurse must clarify the
prescription by repeating the prescription clearly and
precisely to the health care provider. The nurse then writes
the prescription on the health care provider’s prescription
sheet or enters it into the electronic medical record. Under
no circumstances should the nurse try to interpret an
unclear prescription or administer a medication by a route
that has not been expressly prescribed. The nurse must
call the health care provider who gave the telephone
prescription and clarify the prescription.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that indicate that
the nurse should administer the medication without
clarifying the health care provider’s prescription. Review
the procedures for accepting telephone prescriptions if you
had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 14 1 / 1 pts
A nurse is assisting a health care provider in assessing a
hospitalized client. During the assessment, the health care
provider is paged to report to the recovery room. The health care
provider leaves the client’s bedside after giving the nurse a verbal
prescription to change the solution and rate of the intravenous
(IV) fluid being administered. What is the most appropriate
nursing action in this situation?
Calling the nursing supervisor to obtain permission to accept the
verbal prescription
Changing the solution and rate of the IV fluid per the health care
provider’s verbal prescription
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 18/117
Asking the health care provider to write the prescription in the
client’s record before leaving the nursing unit
Correct!
Telling the health care provider that the prescription will not be
implemented until it is documented in the client’s record
Rationale: The health care provider should write all
prescriptions. Verbal prescriptions are not recommended
because they increase the risk for error. If a verbal
prescription is necessary, such as during an emergency, it
should be written and signed by the health care provider
as soon as possible, usually within 24 hours. The nurse
must follow agency policies and procedures regarding
verbal prescriptions. The appropriate nursing action would
be to ask the health care provider to write the prescription
in the client’s record before leaving the nursing unit.
Changing the solution in keeping with the verbal
prescription and contacting the supervisor to obtain
permission to accept the verbal prescription each imply
that the nurse accepts the verbal prescription. Telling the
health care provider that the prescription will not be
implemented until it is documented in the client’s record
delays necessary treatment.
Test-Taking Strategy: Use the process of elimination and
note the strategic words “most appropriate.” Eliminate the
comparable or alike options that imply acceptance of the
verbal prescription by the nurse. To select from the
remaining options, recall the guidelines and principles for
implementing health care provider prescriptions. This will
direct you to the correct option. Review nursing
responsibilities related to verbal prescriptions if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 15 1 / 1 pts
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 19/117
A client scheduled for surgery tells the nurse that he signed an
informed consent for the surgical procedure but was never told
about the risks of the surgery. The nurse serves as the client’s
advocate by undertaking which action?
Reassuring the client that the risks are minimal
Calling the surgeon and asking that the risks be explained to the
client
Correct!
Noting in the client’s record that the client was not told about the
risks of the surgery
Writing a note on the front of the client’s record so that the
surgeon will see it when the client arrives in the operating room
Rationale: A nurse serves as a client advocate by
protecting the right of the client to be informed and to
participate in decisions regarding care. The only option
that ensures that the client will be informed of the risks of
the surgery is contacting the surgeon and asking that the
risks be explained to the client. Telling the client that the
risks are minimal is false reassurance. Putting a note on
the client’s chart or documenting that the client was not
informed about the risks does ensure that the client will be
informed.
Test-Taking Strategy: Use the process of elimination and
guidelines and principles of obtaining informed consent.
Focusing on the data in the question, the words “never
told about the risks of the surgery,” will direct you to the
correct option, the only option that ensures that the client
will be told about the risks. Review the role of a nurse as a
client advocate if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 20/117
Question 16 1 / 1 pts
A nurse is planning to administer an oral antibiotic to a client with
a communicable disease. The client refuses the medication and
tells the nurse that the medication causes abdominal cramping.
The nurse responds, “The medication is needed to prevent the
spread of infection, and if you don’t take it orally I will have to give
it to you in an intramuscular injection.” Which statement
accurately describes the nurse’s response to the client?
The nurse could be charged with battery.
Correct! The nurse could be charged with assault.
The nurse is justified in administering the medication by way of
the intramuscular route, because the client has a communicable
disease.
The nurse will be justified in administering the medication by the
intramuscular route once a prescription has been obtained from
the health care provider.
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 21/117
Rationale: Assault is an intentional threat to bring about
harmful or offensive contact. If a nurse threatens to give a
client a medication that the client refuses or threatens to
give a client an injection without the client’s consent, the
nurse may be charged with assault. Therefore the nurse is
not justified in administering the medication. Battery is any
intentional touching without the client’s consent.
Test-Taking Strategy: Focus on the data in the question
and the nurse’s statement. Note that the nurse threatens
the client. Next, recall the definition of assault, which will
direct you to the correct option. Review violations of client
rights if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Question 17 1 / 1 pts
A nurse discovers that another nurse has administered an enema
to a client even though the client told the nurse that he did not
want one. Which is the most appropriate action for the nurse to
take?
Contact the client’s health care provider.
Correct! Report the incident to the nursing supervisor.
Tell the client that the nurse did the right thing in giving the
enema.
Confront the nurse who gave the enema and tell the nurse that
she is going to be charged with battery.
7/19/2021 Module 5 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
https://concorde.instructure.com/courses/18612/quizzes/83917?module_item_id=1519721 22/117
Rationale: Battery is any intentional touching of a client
without the client’s consent. Such contact may be harmful
to the client, or it may merely be offensive to the client’s
dignity. If a nurse discovers that battery of a client has
occurred, the nurse should report the situation to the
nursing supervisor. Telling the client that the nurse did the
right thing in giving the enema is incorrect because the
other nurse has violated the client’s rights. Confronting the
nurse and telling her that she is going to be charged with
battery would likely result in unnecessary conflict.
Although the health care provider may need to be notified,
the nurse should first report the situation to the nursing
supervisor.
Test-Taking Strategy: Use the process of elimination, and
note the strategic words “most appropriate.” Next, focus
on the subject, client rights. Recalling that any situation
that constitutes a violation of a client’s rights needs to be
reported and remembering the organizational channels of
reporting will direct you to the correct option. Review the
issues surrounding violation of client rights and nursing
responsibilities when a client’s rights have been violated if
you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Lega [Show Less]