HESI/Saunders Module 7: Basic Care and Comfort
Questions With Complete Solutions
A cleansing enema is prescribed for an adult client. The nurse
understands that which is the maximal volume of fluid that can
be administered?
a. 250 mL
b. 500 mL
c. 750 mL
d. 1000 mL Correct Answer d. 1000 mL
Rationale: Cleansing enemas promote complete evacuation of
feces from the colon. They act by stimulating peristalsis through
the infusion of a large volume of solution or local irritation of
the colon's mucosa. The maximal volume of solution for an
adult is 1000 mL.
A clear liquid diet has been prescribed for client who has just
undergone surgery. Which foods should the nurse offer to the
client? Select all that apply.
a. Custard
b. Apple juice
c. Orange juice
d. Chicken broth
e. Orange gelatin
f. Vanilla ice cream Correct Answer b. Apple juice
d. Chicken broth
e. Orange gelatin
Rationale: A clear liquid diet consists of foods, such as apple
juice, chicken broth, and gelatin, which are relatively
transparent. Custard, orange juice, and vanilla ice cream are
components of a full liquid diet.
,A client about to undergo surgery is instructed in postoperative
pain relief measures is asked whether he would like to use a
patient-controlled analgesia (PCA) pump. The client asks the
nurse to describe the pump. Which information should the nurse
provide to the client?
a. The PCA pump eliminates the need for an intravenous (IV)
line
b. The client will be able to deliver his own dose of medication
every 4 hours
c. The client's spouse will be able to administer medication for
the client
d. The client administers his own medication by pressing a
control button Correct Answer d. The client administers his
own medication by pressing a control button
Rationale: A PCA pump contains a cartridge or syringe that
holds the prescribed pain medication. The client pushes a button
to administer a small dose of medication within the limitations
prescribed by the health care provider. The pump allows the
delivery of small doses of medication at short intervals. The
medication is administered by way of the IV route. Only the
client should administer the medication as he or she needs it.
A client arrives at the emergency department after sustaining an
ankle injury, and the health care provider (HCP) prescribes the
application of a cold compress to the ankle. The nurse, preparing
to apply the compress, assesses the ankle and notes that it is
extremely edematous. The nurse should take which action?
a. Apply the cold compress to the ankle
b. Consult with the HCP before applying the cold compress
, c. Apply the cold compress for 20 minutes, and then apply a hot
compress for 20 minutes
d. Elevate the ankle and place cold compresses under and on
top of the ankle Correct Answer b. Consult with the HCP
before applying the cold compress
Rationale: Cold is usually contraindicated if the site of injury is
extremely edematous because it further retards circulation to the
area and prevents absorption of the interstitial fluid. For this
reason, applying the cold compress to the ankle and elevating
the ankle and placing a cold compress under and on top of the
ankle are both incorrect. The nurse would not place heat on an
injury without a prescription to do so. The nurse would consult
with the HCP about the prescription for cold application.
A client asks a nurse about complementary and alternative
measures to promote sleep. What should the nurse suggest?
a. Herbal therapy
b. Acupuncture
c. Muscle relaxation techniques
d. Traditional Chinese medicine Correct Answer c. Muscle
relaxation techniques
Rationale: A simple technique such as muscle relaxation can
help ease any existing anxiety and promote sleep. In
acupuncture, special needles are inserted into specific points on
the body as a means of modifying the perception of pain,
normalizing physiological function, or preventing or treating
disease. Traditional Chinese medicine is focused on restoring
and maintaining a balanced flow of vital energy; interventions in
this discipline include acupressure, acupuncture, herbal
therapies, diet, meditation, and tai chi and qigong (forms of
exercise focused on breathing, visualization, and movement).
, Herbal therapy involves the use of herbs (plants or plant parts).
Some herbs have been found to be safe, but others, even in small
amounts, can be toxic, and the nurse would not recommend the
use of such a therapy to a client. If the client is taking
prescription medications, the client should consult with the
healthcare provider regarding the use of herbs, because serious
interactions may occur.
A client complains of feeling fatigued because of the need to get
up several times during the night to urinate. The nurse
documents that the client is experiencing which problem?
a. Anuria
b. Oliguria
c. Polyuria
d. Nocturia Correct Answer d. Nocturia
Rationale: Nocturia is excessive urination at night. Anuria is the
inability to produce urine. Oliguria is a diminished capacity to
form urine. Polyuria is excessive urine output.
A client has a serum sodium level of 151 mEq/L (151 mmol/L),
and the nurse provides instruction regarding foods to avoid.
Which menu choice by the client indicates to the nurse that the
client needs further instruction?
a. Fish
b. Spinach
c. Rhubarb
d. American cheese Correct Answer d. American cheese
Rationale: The client's laboratory value reflects hypernatremia;
the normal serum sodium range is 135 to 145 mEq/L (135-145
mmol/L). On the basis of this finding, the nurse would instruct
the client to avoid foods high in sodium. These would include
Questions With Complete Solutions
A cleansing enema is prescribed for an adult client. The nurse
understands that which is the maximal volume of fluid that can
be administered?
a. 250 mL
b. 500 mL
c. 750 mL
d. 1000 mL Correct Answer d. 1000 mL
Rationale: Cleansing enemas promote complete evacuation of
feces from the colon. They act by stimulating peristalsis through
the infusion of a large volume of solution or local irritation of
the colon's mucosa. The maximal volume of solution for an
adult is 1000 mL.
A clear liquid diet has been prescribed for client who has just
undergone surgery. Which foods should the nurse offer to the
client? Select all that apply.
a. Custard
b. Apple juice
c. Orange juice
d. Chicken broth
e. Orange gelatin
f. Vanilla ice cream Correct Answer b. Apple juice
d. Chicken broth
e. Orange gelatin
Rationale: A clear liquid diet consists of foods, such as apple
juice, chicken broth, and gelatin, which are relatively
transparent. Custard, orange juice, and vanilla ice cream are
components of a full liquid diet.
,A client about to undergo surgery is instructed in postoperative
pain relief measures is asked whether he would like to use a
patient-controlled analgesia (PCA) pump. The client asks the
nurse to describe the pump. Which information should the nurse
provide to the client?
a. The PCA pump eliminates the need for an intravenous (IV)
line
b. The client will be able to deliver his own dose of medication
every 4 hours
c. The client's spouse will be able to administer medication for
the client
d. The client administers his own medication by pressing a
control button Correct Answer d. The client administers his
own medication by pressing a control button
Rationale: A PCA pump contains a cartridge or syringe that
holds the prescribed pain medication. The client pushes a button
to administer a small dose of medication within the limitations
prescribed by the health care provider. The pump allows the
delivery of small doses of medication at short intervals. The
medication is administered by way of the IV route. Only the
client should administer the medication as he or she needs it.
A client arrives at the emergency department after sustaining an
ankle injury, and the health care provider (HCP) prescribes the
application of a cold compress to the ankle. The nurse, preparing
to apply the compress, assesses the ankle and notes that it is
extremely edematous. The nurse should take which action?
a. Apply the cold compress to the ankle
b. Consult with the HCP before applying the cold compress
, c. Apply the cold compress for 20 minutes, and then apply a hot
compress for 20 minutes
d. Elevate the ankle and place cold compresses under and on
top of the ankle Correct Answer b. Consult with the HCP
before applying the cold compress
Rationale: Cold is usually contraindicated if the site of injury is
extremely edematous because it further retards circulation to the
area and prevents absorption of the interstitial fluid. For this
reason, applying the cold compress to the ankle and elevating
the ankle and placing a cold compress under and on top of the
ankle are both incorrect. The nurse would not place heat on an
injury without a prescription to do so. The nurse would consult
with the HCP about the prescription for cold application.
A client asks a nurse about complementary and alternative
measures to promote sleep. What should the nurse suggest?
a. Herbal therapy
b. Acupuncture
c. Muscle relaxation techniques
d. Traditional Chinese medicine Correct Answer c. Muscle
relaxation techniques
Rationale: A simple technique such as muscle relaxation can
help ease any existing anxiety and promote sleep. In
acupuncture, special needles are inserted into specific points on
the body as a means of modifying the perception of pain,
normalizing physiological function, or preventing or treating
disease. Traditional Chinese medicine is focused on restoring
and maintaining a balanced flow of vital energy; interventions in
this discipline include acupressure, acupuncture, herbal
therapies, diet, meditation, and tai chi and qigong (forms of
exercise focused on breathing, visualization, and movement).
, Herbal therapy involves the use of herbs (plants or plant parts).
Some herbs have been found to be safe, but others, even in small
amounts, can be toxic, and the nurse would not recommend the
use of such a therapy to a client. If the client is taking
prescription medications, the client should consult with the
healthcare provider regarding the use of herbs, because serious
interactions may occur.
A client complains of feeling fatigued because of the need to get
up several times during the night to urinate. The nurse
documents that the client is experiencing which problem?
a. Anuria
b. Oliguria
c. Polyuria
d. Nocturia Correct Answer d. Nocturia
Rationale: Nocturia is excessive urination at night. Anuria is the
inability to produce urine. Oliguria is a diminished capacity to
form urine. Polyuria is excessive urine output.
A client has a serum sodium level of 151 mEq/L (151 mmol/L),
and the nurse provides instruction regarding foods to avoid.
Which menu choice by the client indicates to the nurse that the
client needs further instruction?
a. Fish
b. Spinach
c. Rhubarb
d. American cheese Correct Answer d. American cheese
Rationale: The client's laboratory value reflects hypernatremia;
the normal serum sodium range is 135 to 145 mEq/L (135-145
mmol/L). On the basis of this finding, the nurse would instruct
the client to avoid foods high in sodium. These would include
