lOMoAR cPSD|19500986
Nonmaleficence Correct
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
Telling the client that he or she may not leave the hospital Correct
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
Awarded 1.0 points out of 1.0 possible points.
Awarded 0.0 points out of 1.0 possible points.
2023 HESI PN EXIT EXAM/PN HESI EXIT /HESI EXIT PN
NEWEST EXAM QUESTIONS AND CORRECT
ANSWERS|ALREADY GRADED A+
- 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?
A. Fidelity
B.
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C. Autonomy
D. Justice - Which action by the nurse represents the ethical principle of beneficence?
A.
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B. The nurse follows a plan of care designed to relieve pain in a client with cancer. Incorrect
C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.
D. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. - 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. Threatening to give a client a medication against his or her will
C. Observing the provision of care to the client without the client’s permission
D.
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Awarded 1.0 points out of 1.0 possible points.
The nurse administers an immunization to a child even though it may cause discomfort. Correct
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
lOMoAR cPSD|19500986
1/30
lOMoAR cPSD|19500986
Check the client s level of consciousness and vital signs Correct
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
Donning sterile gloves to change an abdominal wound dressing Correct
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 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
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
Awarded 1.0 points out of 1.0 possible points.
Awarded 1.0 points out of 1.0 possible points.
- 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?
A. Ask the nursing assistant to complete an incident report
B.
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C. Contact the unit secretary on the intercom and ask that the client’s health care provider be called
D. Ask the nursing assistant to assist in getting the client back to bed - Which action exemplifies the use of evidence-based practice in the delivery of client care?
A. Advising a client to agree to the treatment recommended by her health care provider
B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
C.
ID: 18630150587
D. Encouraging a client to take an herbal substance to treat his insomnia - 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.
A. Prescribing treatments specific to the client s needs
B. Establishing a safe and cost-effective plan of care with the client Correct
C. Evaluating and updating the plan of care as needed Correct
D. Coordinating consultations and referrals to facilitate discharge Correct
E. Assessing the client s needs for home supplies and equipment Correct
ID: 18630149783 - 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 crash cart to ensure that all needed supplies are readily available should an emergency arise
B. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift
C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed
D.
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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
Awarded 4.0 points out of 4.0 possible points.
lOMoAR cPSD|19500986
Explain to the client why the wedding band must be removed. Correct
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. Therefo re 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
Awarded 1.0 points out of 1.0 possible points.
Awarded 1.0 points out of 1.0 possible points.
- 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?
A.
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B. Ask the client to remove the necklace and place it in the top drawer of the bedside table.
C. Ask the client whether the necklace is gold.
D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure. - A 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. The nurse should
take which action?
A. Tape the wedding band in place.
B. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery.
C.
ID: 18630149769
D. Ask the client whether she would like to remove the wedding band or wear it to surgery. - 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 ID: 18630149775
the medal. What is the most appropriate action for the nurse to take?
A. 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
B. Asking the client to remove the medal until the x-ray has been completed
C. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct
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
3/30
Awarded 1.0 points out of 1.0 possible points.
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
Ask the client for permission to lock the necklace in the hospital safe. Correct
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