Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Question 1 1 /
... [Show More] 1 pts
Which event would require a nurse to complete and file an
incident report?
A client has a seizure.
The nurse determines that a client would benefit from the use of
a walker to ambulate.
The nurse, preparing an intravenous infusion, notes that the
battery of an intravenous infusion pump is not working.
When a visitor suddenly becomes weak and dizzy, the nurse
checks the visitor’s blood pressure and takes the visitor to the
emergency department for treatment.
Correct!
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Rationale: An incident is any event that is not consistent
with the routine operation of a health care unit or routine
care of a client. Examples of incidents include client falls,
needlestick injuries, a visitor having symptoms of illness,
medication administration errors, accidental omission of
prescribed therapies, and circumstances leading to injury
or a risk for injury. An incident report does not need to be
filed if a client has a seizure unless the client sustains
injury as a result of the seizure. If the nurse determines
that a client would benefit from the use of a walker to
ambulate, he or she should take the appropriate action to
obtain one. If the nurse notes that the battery of an
intravenous infusion pump is not working, he or she
should obtain a functioning pump and send the
nonfunctioning pump to the appropriate department for
repair.
Test-Taking Strategy: Use knowledge of the subject,
reasons for filing an incident report, to assist you with the
process of elimination. Read each option carefully.
Recalling that an incident is any event that is not
consistent with the routine operation of a health care unit
or routine care of a client will direct you to the correct
option. Review the reasons for filing an incident report 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 2 1 / 1 pts
A nurse, charting the administration of medications to an
assigned client at 9 p.m., notes that atenolol (Tenormin) was
prescribed to be administered at 9 a.m. instead of 9 p.m. The
nurse checks the client’s vital signs, completes an incident report,
and calls the health care provider to report the error. The health
care provider tells the nurse that an incident report is not needed
but instructs her to monitor the client during the night for
hypotension. What action should the nurse take?
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Notifying the nursing supervisor Tearing up and discarding the incident report
Telling the health care provider that the error warrants the
completion of an incident report
Correct!
Telling the nursing supervisor that the health care provider did not
want an incident report completed and filed
Rationale: Incident reports are an important part of a
health care agency’s quality improvement program. An
incident is any event that is not consistent with the routine
operation of a health care unit or routine care of a client.
An example of an incident is administering a medication at
a time at which it is not prescribed to be given. Whenever
an incident occurs, an incident report is completed and
filed in accordance with agency guidelines. The nursing
supervisor would be notified of the incident; however, on
the basis of the data in the question, the nurse should tell
the health care provider that the error warrants completion
and follow-through with an incident report. Therefore, the
other options are incorrect.
Test-Taking Strategy: Focus on the subject of the
question, the health care provider’s telling the nurse that
an incident report is not needed. Eliminate the comparable
or alike options that involve notifying the nursing
supervisor. To select from the remaining options, recall the
purpose of an incident report to select the correct option.
Review the procedures involved in completing and 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: Ethical/Legal
Question 3 1 / 1 pts
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse,
providing instructions to a nursing assistant about caring for the
client, tells the assistant to take which action?
To transfer the client to a semiprivate room That gloves only are needed to care for the client
To wear gloves and a gown when changing the client’s bed linen
Correct!
To wear a gown when caring for the client and remove the gown
immediately after leaving the client s room
Rationale: Contact precautions require the use of gloves,
gown, and goggles if direct client contact is anticipated.
The client should be placed in a private room or, if a
private room is not available, in a semiprivate room with
another client who has active infection with the same
microorganism but no other infection. The nursing
assistant would remove the protective gear before leaving
the client’s room.
Test-Taking Strategy: Use the process of elimination.
Eliminate the option that includes the closed-ended word
“only.” Next eliminate the option that involves removal of
the gown after leaving the client’s room. To select from the
remaining options, read each carefully and visualize the
procedure instituted for contact precautions, which will
direct you to the correct option. If you had difficulty with
this question, review contact precautions.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Question 4 1 / 1 pts
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The mother of a 3-year-old calls a neighbor who is a nurse and
reports that her child just drank some window cleaner that had
been stored in a cabinet. The nurse should instruct the mother to
immediately take which action?
Correct! Call a poison control center.
Administer an excessive amount of fluids to induce vomiting.
Call an ambulance to bring the child to the emergency
department.
Leave a message at the health care provider answering service
about the incident.
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Rationale: When a poisoning occurs, a poison center
should be called immediately. Vomiting should not be
induced if the victim is unconscious or if the substance
ingested was a strong corrosive or petroleum product.
Also, vomiting should not be induced unless a health care
provider has given specific instructions to induce vomiting.
Neither calling an ambulance nor calling the health care
provider’s answering service is the immediate action,
because either would delay treatment. Additionally, the
health care provider would immediately make a referral to
the poison control center. The poison control center may
advise the mother to bring the child to the emergency
department; if this is the case, the mother should then call
an ambulance.
Test-Taking Strategy: Note the strategic word
“immediately” in the query of the question. First, recalling
that vomiting should not be induced without appropriate
advice to do so will help you eliminate the option that
involves inducing vomiting. Next eliminate the comparable
or alike options that will delay treatment (i.e., calling an
ambulance and leaving a message with the answering
service). Review immediate poison control measures 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 5 1 / 1 pts
A hurricane is forecast to make landfall in 48 hours, and the staff
of the emergency department of an area hospital is advised to
prepare for casualties. Which action should the nurse who
receives the telephone call regarding this warning take first?
Correct! Activating the agency disaster plan
Supplying the triage rooms with additional equipment
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Increasing the number of nursing staff for the day on which the
hurricane is expected
Calling the hospital maintenance department to secure the
building against the storm
Rationale: In an external disaster, many people may be
brought to the emergency department for treatment.
Although increasing the nursing staff and supplying the
triage rooms with additional equipment may be steps in
preparing for casualties, the initial action by the nurse
manager must be activation of the disaster plan. Calling
the hospital maintenance department to secure the
building from the storm is not a responsibility that falls
within the scope of nursing management.
Test-Taking Strategy: Note the strategic word “first” in the
query of the question. Use the process of elimination in
determining the priority action. Note that the correct option
is the umbrella option. Also remember that other
necessary activities will be initiated once the agency
disaster plan has been activated. Review procedures
related to management in times of disaster if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Question 6 1 / 1 pts
A home health nurse has instructed a client about safety
measures during the use of an oxygen concentrator in the home.
Which statements by the client indicate to the nurse that the client
has understood the directions? Select all that apply.
Correct! “I need to follow the oxygen prescription exactly.”
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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“I can use my electric razor while I’m using oxygen.”
“I have to keep the oxygen concentrator out of direct sunlight.”
Correct!
“I need to keep the oxygen concentrator as close to the wall as
possible or put it in a corner.”
“I have to tell everyone that they can’t smoke or have an open
flame within 10 feet of the oxygen concentrator.”
Correct!
Rationale: The client should follow the oxygen prescription
exactly. The use of electric razors or other equipment that
could emit sparks should be avoided while oxygen is in
use, because fire and injury to the client could result. The
oxygen concentrator is kept out of direct sunlight and
slightly away from walls and corners to permit adequate
air flow. The client should not allow smoking or any type of
flame within 10 feet of the oxygen source. Other measures
include having telephone numbers for the health care
provider, nurse, and oxygen vendor available and teaching
the client signs and symptoms requiring emergency care.
Test-Taking Strategy: Recall knowledge of the subject,
oxygen safety measures, to assist you with eliminating
options. Recall that one hazard associated with oxygen is
ignition, which could result from heat in the form of flames
or sparks. Evaluating the question from this perspective,
eliminate the options that are unsafe. Review oxygen
safety measures if you had difficulty with this question.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Question 7 1 / 1 pts
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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A nurse is providing instructions to a nursing student who will be
caring for a client in hand restraints. The nurse instructs the
nursing student to release the restraints to permit muscle
exercise how frequently?
Correct! Every 2 hours
Every 3 hours Every 4 hours Every 30 minutes
Rationale: The nurse should assess the restraints and the
client’s circulatory status and skin integrity every 30
minutes. Restraints must be released at least every 2
hours to permit muscle exercise and promote circulation.
Agency guidelines regarding the use of restraints should
always be followed.
Test-Taking Strategy: Knowledge regarding the subject,
the use of restraints, is necessary to answer this question.
Noting the strategic words “release the restraints” will help
direct you to the correct option. Review nursing
responsibilities regarding the use of restraints if you had
difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Question 8 1 / 1 pts
A community health nurse working in a school setting is
concerned because parents are not participating in health
activities designed to promote child safety. In this situation, which
is the most appropriate initial action?
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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Implementing a child safety program Planning a focused child safety program
Performing an analysis of health problems related to child safety
Determining the appropriateness of the planned health activity
Correct!
Rationale: In this situation, the best initial action would be
to determine the appropriateness of the planned health
activities. This would be followed by analysis, planning,
and implementation.
Test-Taking Strategy: Use the steps of the nursing process
to answer the question. Note that the correct option
involves the process of data collection, the first step of the
nursing process. Review the procedure for planning health
activities to provide safety 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 9 1 / 1 pts
The nurse administers a dose of ramipril 2.5 mg to a client at 9
a.m. While documenting administration of the medication, the
nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed
dose. The nurse assesses the client, completes an incident
report, and notifies the health care provider and nursing
supervisor of the error. What statement does the nurse add to the
client’s record?
An incident report was completed and filed.
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Correct! Ramipril (Altace) 2.5 mg was administered at 9 a.m.
Twice the amount of the prescribed ramipril was administered at
9 a.m.
Client’s blood pressure was 128/82 mm Hg after the
administration of the incorrect dose of ramipril.
Rationale: After an incident, the nurse would document a
concise and objective description of what occurred and
any follow-up actions taken in the client’s record. The
nurse would not document in the client’s record that an
incident report was completed. Nor would the nurse
document that twice the prescribed dose was given or that
an incorrect dose was given.
Test-Taking Strategy: Focus on the data in the question.
Recall that notes made in a client’s record must be
objective. Eliminate the comparable or alike options that
indicate that an incorrect dose of medication was
administered. Next note that the correct option clearly and
accurately describes the incident in an objective manner.
Review documentation of a medication error or other
incident if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Ethical/Legal
Question 10 1 / 1 pts
A home health nurse has been called to the home of an older
postoperative cardiovascular client by the client’s son. The son
tells the nurse, “We’re using a hospital bed here at home, but my
mother has fallen out of bed three times.” Which observation by
the nurse reflects an increased risk of this client’s falling out of
bed?
7/19/2021 Module 6 Exam: HESI VN TXGRP 1912COHORT(VNE 39)
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The client’s bed is in a low position. The client is oriented to person, place, and time. The caregiver uses the overbed table for feedings.
The caregiver leaves both siderails down while the client is in
bed.
Correct!
Rationale: Leaving the siderails of older client’s bed down
may increase the client’s risk of falling. The aging process
also increases this client’s potential for falls; therefore,
evaluating the safety of the environment is a necessity.
Keeping the client’s bed in a low position, orientating the
client to the environment, and using the overbed table for
feedings are all ways to help ensure the client’s safety.
Test-Taking Strategy: Use the process of elimination,
focusing on the subject, an observation of an unsafe
practice. Noting that the question indicates that the bed is
in the low position and that the client is oriented will assist
you in eliminating these options. To select from the
remaining options, choose the one that identifies an
unsafe practice. Review the causes of falls in an older
client if you had difficulty with this question.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Data Collection
Content Area: Safety
Ques 1 / 1 pts tion 11
A community health nurse is providing information to local
residents about the transmission of anthrax. Through which body
systems does the nurse tell the residents that anthrax can be
contracted? Select all that apply [Show Less]