NSG 201 Saunders Review Test 1 (Download To Score) Latest Update

1.ID: 6
A client is being discharged home after a routine hip replacement surgery. The nurse is instructing the client on how to prevent postoperative complications. What statements by the client would indicate the need for further teaching? Select all that apply. A. “Limiting fiber is necessary to avoid diarrhea.” Correct B. “I should empty my bladder when I feel the urge.” C. “Avoiding pain medication will prevent constipation.” Correct D. “I should drink plenty of liquids like iced tea or coffee.” Correct E. “I should continue with my physical therapy and walking.”
Rationale: Constipation is common after surgery due to pain medication, decreased movement, and anesthesia. Fiber intake should be encouraged as it promotes the prevention of stool retention. Although pain medication can cause constipation, it should not be avoided in the post-operative period. Drinking plenty of fluids is encouraged for both bowel and bladder maintenance, but the client should choose non-caffeinated options. Physical therapy, walking, and exercise will help prevent constipation. Emptying the bladder when the urge is present can help prevent urinary tract infections.
Test taking strategy: Note the strategic words need for further teaching. These words indicate a negative event query and the need to select the incorrect client statements. Think about the measures needed for bowel and bladder control to answer correctly. Review: bowel and bladder maintenance.
Level of Cognitive Ability: Evaluating
Client Need: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Fundamentals of Care: Perioperative Care
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health Promotion, Teaching and Learning/Patient Education
References: Giddens, J. (2013). Concepts for nursing practice. (p. 143). St. Louis, MO: Mosby.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 969, ). St. Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
2.ID: 8
The nurse is caring for a Vietnamese client diagnosed with tuberculosis. The client speaks limited English. What should the nurse do to ensure the client and family receives the most accurate information? Select all that apply. A. Provide culturally sensitive education. Correct B. Encourage family members to obtain a tuberculosis skin test. Correct C. Provide written instructions in English for the client to reference. D. Encourage the client and family to wash all dishes by hand to prevent the spread of infection. Incorrect E. Urge all family and close contact community members to seek and complete treatment to enhance compliance. Correct
Rationale: As always, the nurse must provide culturally sensitive education. Because tuberculosis is highly contagious, all family members and close community members should have a tuberculosis skin test, seek treatment, and remain compliant. A full course of 6-9 months of treatment is needed to prevent re-infection. Instructions written in English are not helpful for the client with limited English skills. Washing dishes by hand is not the best way to prevent infection; rather a dishwasher should be used if available.
Test Taking Strategy: Focus on the strategic word most to select correct options that relate to appropriate teaching for both the client and family members. Also, focusing on the data in the question will assist in answering. Review: Tuberculosis
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Implementation
Content Area: Fundamentals of Care: Infection Control
Priority Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
References: Giger, J. (2013). Transcultural nursing assessment & intervention. (6th
ed. p. 445, 455). St. Louis: Mosby.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 533). St. Louis: Mosby.
Awarded 1.0 points out of 3.0 possible points.
3.ID: 4
A client with anxiety has just been seen by the health care provider and has been prescribed alprazolam. The client asks the nurse how long it will take for the medication to build up a steady state in her body. If the half life of this medication is approximately 11 hours, approximately how long will it take for this medication to build up and reach a steady state? _____ hours
Incorrect
Correct Responses A. 55
Rationale: The half life of a medication is the amount of time it takes for 50% of the medication to leave the system. Steady state is the point where the concentration of the medication is equal based on the medication leaving the body system and new medication entering the system. Alprazolam has a half life of 11 hours. For all medications, it takes approximately five times the half life to reach steady state. Therefore the steady state for this medication is 55 hours (11 x 5 = 55).
Test taking strategy: Focus on the subject, the time it takes to achieve a steady state of alprazolam in the body. Use the half life of the medication to calculate. Follow the calculation for steady state of five times the half life and verify your answer using a calculator. Review: half life of alprazolam.
Level of Cognitive Ability: Understanding
Client Need: Safe and Effective Care Environment
Integrated Process: Nursing Process/Assessment
Content Area: Fundamentals of Care: Medications and Administration
Priority Concepts: Cellular Regulation, Safety
HESI Concepts: Cellular Regulation, Safety
References: Rosenjack Burchum, Rosenthal (2016), pp. 374-375
Stuart, G. (2013). Principles and practice of psychiatric nursing (10th ed., p. 526). St. Louis, MO: Mosby.
Awarded 0.0 points out of 1.0 possible points.
4.ID: 9
The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm (refer to figure). What is the initial nursing action?
A. Check for a pulse Correct B. Notify the health care provider C. Obtain a 12 lead electrocardiogram (ECG) D. Begin cardiopulmonary resuscitation (CPR)
Rationale: Ventricular tachycardia can be stable or unstable depending on whether the client has a pulse or not. In this case, assessing the client’s pulse is the initial action. Obtaining a 12 lead ECG and notifying the health care provider may be necessary but are not initial actions. Initiating CPR may be necessary of the ventricular tachycardia becomes unstable and cardiac arrest occurs.
Test-Taking Strategy: Note eh strategic word, initial. Use the steps of the nursing process and recall that assessment is the first step and the first action to take. Review: Ventricular Tachycardia
Level of Cognitive Ability: Analyzing
Client Need: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health: Cardiovascular
Priority Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 799-800). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 3
A mother brings her 9-month-old child to see the pediatrician and has concerns that the child may have a developmental delay because the child cannot roll over yet. for the nurse should ask the mother about which risk factors associated with a developmental delay? Select all that apply. A. Age B. Race Incorrect C. Income Correct D. Chronic illness Correct E. Low birth weight Correct F. Environmental exposure to toxins Correct
Rationale: Developmental delays can occur at any age, however, it is most commonly seen in infancy through adolescence. Developmental delays can occur regardless of race. Children living in poverty, those with chronic illnesses, low birth weight, or exposure to environmental exposure to toxins are at a higher risk for developmental delays.
Test taking strategy: Focus on the subject, risk factors associated with a developmental delay. Recall that developmental delays that occur in children are caused by prenatal, birth, social, and health risks. This will help eliminate the incorrect answers of age and race. Review: risk factors for developmental delays
Level of Cognitive Ability: Analyzing
Client Need: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Developmental Stages: Infancy to Adolescence
Priority Concepts: Development, Patient Education
HESI Concepts: Developmental, Teaching and Learning/Patient Education
References: Giddens, J. (2013). Concepts for nursing practice. (p. 4). St. Louis, MO: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th
ed. pp. 18-19, 432, 777). St Louis: Mosby.
Awarded 1.0 points out of 4.0 possible points.
6.ID: 8
The nurse in a pediatric unit is planning the staff assignments for children with developmental delays. When planning the assignment, the nurse decides to assign those children who have social or emotional delays amongst different nurses. Which children should be assigned to different nurses? Select all that apply. A. A child with autism Correct B. An infant with fetal alcohol syndrome Incorrect C. A child with attention deficit disorder D. A child with generalized anxiety disorder Correct E. A child with expressive language disorder Incorrect
Rationale: A developmental delay is defined as not meeting the expected developmental level. Social and emotional developmental delays include those affecting personality, emotion, or behaviors. Two examples are autism, and generalized anxiety disorder. Attention deficit disorder and fetal alcohol syndrome are classified as cognitive developmental delays, and expressive language disorder is a communication developmental delay.
Test Taking Strategy: Focus on the subject, planning assignments and children with social and emotional developmental delays. Use knowledge of the different types of developmental delays to eliminate those options. Review: developmental delays
Level of Cognitive Ability: Creating
Client Need: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Developmental Stages: Infancy to Adolescence
Priority Concepts: Care Coordination, Development
HESI Concepts: Care Coordination, Development
References: Giddens, J. (2013). Concepts for nursing practice. (p. 4, 8-9). St. Louis, MO: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 147-148). St Louis: Mosby.
McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternalchild nursing (4th
ed., pp. ). St. Louis: Elsevier.
Awarded -1.0 points out of 2.0 possible points.
7.ID: 6
The client has been prescribed amoxiciilin 250 mg three times daily for sinusitis. The medication is supplied in a 500 mg tablet. How many tablet(s) would the nurse prepare every 8 hours to administer the correct dose? Fill in the blank. Record the answer using one decimal place. _____________ tablet(s)
Correct
Correct Responses A. 0.5
Rationale:
Use the medication calculation formula to calculate the correct dose.
Desired 250 mg
__________ = __________ = 0.5 tablets

Available = 500mg
Test-Taking Strategy: Focus on the subject, a medication calculation. Once you have performed the calculation, verify your answer with a calculator. Be aware of non-important numbers in the question that can be confusing. In this question, three times a day and 8 hours are not used in the calculation. Lastly, ensure that your answer makes sense. Review: medication calculations.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
Content Area: Fundamental of Care: Medication/IV Calculations
Priority Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques
(8th ed., pp. 486-487). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 1
The nurse is caring for a client admitted to the hospital for shortness of breath and edema in both lower extremities. The client is prescribed furosemide 40mg by the intravenous route once daily. What information in the chart would warrant the nurse to verify continuing the prescription with the health care provider (HCP)? Refer to chart.
H i s t o r y a n d P h y s i c a l
La bo rat or y Fin din gs
M ed ic at io ns
E x p i r
Bl oo d pr es
Li si no pr il atoryralesonauscultation sur e 14 5/ 94mm Hg 20m g or all y da ily
PeripheralVa
Se ru m Po tas siu m 3. 5 m Eq /L
At or va st at in 10m g or all s c u l a r D i s e a s e ( P V D ) (3. 5 m m ol/ L) y at be dt im e A. Expiratory rales B. Atorvastatin prescription C. Peripheral vascular disease D. Potassium level of 3.5 mEq/L (3.5 mmol/L) Correct
Rationale: Furosemide is a potassium-losing diuretic. The serum potassium level of 3.5mEq/L (3.5 mmol/L) is on the lower limit of normal, and the nurse should anticipate that the potassium level would drop with the administration of furosemide. Therefore, the nurse should verify continuing the prescription if this potassium level was noted. Expiratory rales are an expected finding with fluid overload and furosemide would be an appropriate treatment. Atorvastatin and peripheral vascular disease are not impacted by the administration of furosemide.
Test-Taking Strategy: Focus on the subject, the need to verify continuing the prescription. Note the data in the question and that the client is receiving furosemide. Recall that furosemide is a potassium-losing diuretic. Think about the side and adverse effects of this medication to answer correctly. Review: furosemide
Level of Cognitive Ability: Synthesizing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Analysis
Content Area: Fundamentals of Care: Fluids & Electrolytes
Priority Concepts: Collaboration, Safety
HESI Concepts:
Collaboration/Managing Care, Safety
Reference: Rosenjack Burchum, Rosenthal (2016), pp. 456-457.
Awarded 1.0 points out of 1.0 possible points.
9.ID: 3
A nurse employed at a nursing home is caring for a client who has recently been transferred from the hospital to the nursing home. The client is confused and is acting out. The nurse suspects the client is suffering from relocation stress. The nurse should include which helpful actions in the plan of care? Select all that apply. A. Encourage friends and family to visit frequently. Correct B. Establish a trusting relationship with the client as soon as possible. Correct C. Change rooms frequently to prevent the client from becoming bored. D. Ensure the client is an active part of decision making regarding their care. Correct E. Allow the client to move around the halls as desired to decrease the confusion and acting-out.
Rationale: Relocation stress can occur when a client is removed from their usual surrounding such as home. In order to provide safe and quality care, encourage friends and family to visit the client often and establish a trusting relationship with the client as soon as possible. It is important for the client to have an active role in decision-making. In order to lessen confusion, the nurse should provide the client time to become familiar with the immediate surroundings such as his or her room before allowing or encouraging ambulation to new surroundings; allowing the client to move around the halls as desired may increase confusion and acting-out behaviors. Likewise, changing the client’s room frequently may increase confusion.
Test-Taking Strategy: Focus on the subject, relocation stress. Also note that the client is confused and acting-out. Think about this type of stress and the manifestations and what you might expect from a client who is experiencing relocation stress. Use that knowledge to determine appropriate nursing actions. Review: relocation stress.
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process: Planning
Content Area: Fundamentals of Care: Safety
Priority Concepts: Safety, Stress
HESI Concepts: Safety, Stress and Coping
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th
ed. p. 19). St. Louis, MO: W.B. Saunders Company.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed., p. 70). St. Louis: Mosby.
Awarded 2.0 points out of 3.0 possible points.
10.ID: 2
The nurse is caring for a client in the hospital and is reconciling the client’s home medications. The client is taking Lactobacillus,
a probiotic over-the counter medication. The nurse is discussing the supplement with the client. What statement by the client would warrant the need for further teaching? Select all that apply. A. “I can take my probiotic at any time of day or night.” Correct B. “Probiotics can be found in yogurt and some juices.” C. “I should take this supplement to prevent gas and bloating.” Correct D. “Because I’m lactose intolerant, a probiotic would not benefit me.” Correct E. “This supplement will help me avoid getting diarrhea from antibiotics.” Incorrect
Rationale: Probiotics are live microorganisms that are similar to those found naturally occurring in the gastrointestinal tract. Probiotics should be taken as directed, usually with a meal, and can have a side effect of gas and bloating. If gas an bloating do occur, the client should be advised to try a different type of probiotic. Probiotics are recommended for those clients who are lactose intolerant. Probiotics are found in foods such as yogurts and some juices and can be helpful to treat antibiotic-associated diarrhea.
Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select he incorrect client statements. Use knowledge of probiotic supplements to determine the correct options. Review: the uses and effects of probiotics
Level of Cognitive Ability: Evaluating
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Pharmacology: Gastrointestinal Medications
Priority Concepts: Client Education, Health Promotion
HESI Concepts: Health Promotion, Teaching and Learning/Patient Education
References: Ignatavicius, D. M., & Workman, L. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th
ed. p. 10). St. Louis, MO: W.B. Saunders Company.
Rosenjack Burchum, Rosenthal (2016), pp. .
Awarded 1.0 points out of 3.0 possible points.
11.ID: 8
The nurse educator is presenting a lecture on child neglect. Which statement by one of the students indicates that the teaching has been effective? Select all that apply. A. “A sign of neglect are bruises on the child’s body.” Correct B. “Neglected children show aggression after age 10.” C. “Neglect is parental failure to meet a child’s basic needs.” Correct D. “Neglected children often have learning problems and low selfesteem.” Correct E. “Neglect occurs when a parent does not seek medical attention for a sick child.” Correct
Rationale: Neglect has serious consequences for children. Basically, there are 5 types of child neglect: physical neglect; psychological or emotional neglect; medical neglect; mental health neglect; and educational neglect. One sign of physical neglect is bruising on the child’s body. Neglect is the parental failure to meet a child’s basic needs such as: food, shelter, comfort, love, and medical attention. Consequences of neglect include: learning problems, low self-esteem, developmental delays, passivity and juvenile delinquency. Children who are neglected often show signs of aggression before the age of 2.
Test-Taking Strategy: Focus on the strategic word “effective”. Determine which statements indicate that the teaching has been effective, by determining which statements are true. Note the age of the child in option 2. This will assist in eliminating this option. Review: Signs of child abuse.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Giddens Concepts: Health Care Law, Interpersonal Violence
HESI Concepts: Health Policy/Systems – Health Care Law, Violence
References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 353). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. p. 562). St Louis: Mosby.
Awarded 3.0 points out of 4.0 possible points.
12.ID: 7
The nurse is obtaining the medical history from an older client with a black eye and bruising to the head. The nurse suspects that the client has been abused, and that there may be a history of abuse. Which statement by the client indicates the need for further questioning by a social worker? Select all that apply. A. “Perhaps I somehow did this to myself.” Correct B. “I tripped over a rug and now I have a black eye.” Correct C. “I got into a car accident yesterday and the airbag deployed.” D. “Well, I don’t remember anything that would have caused the injuries.” Correct E. “Sometimes my grandson becomes angry with me when I can’t give him money.” Correct
Rationale: There are certain elements in the medical history that raise concern for physical abuse. Perpetrators may provide a history of events that are incomplete or inconsistent with injuries seen. Many individuals who experience interpersonal violence are unable or afraid to provide an accurate account of events. Often individuals will provide a history of trauma that is inconsistent with the physical examination. It is unlikely that these injuries were self-inflicted or the result of tripping over a rug. Having no recollection of how an injury occurred should be an alert to the nurse, as well as statements that another person caused the injury. The nurse should immediately report this to a health care provider and the social worker so that proper intervention and follow-up can be arranged. A car accident with air bag deployment could reasonably cause the injuries to the client. The nurse should continue on with assessment, treatment and arrange follow-up care for the client.
Test-Taking Strategy: Focus on the subject, “abuse to an older client”. Determine which statements made by the client would indicate that abuse may be occurring. Abuse individuals often make statements that do not correlate with injuries. Eliminate option 3, because air bag deployment could have caused the client’s injuries. Review: Signs of abuse in the older client.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Leadership/Management
Giddens Concepts: Clinical Judgment, Interpersonal Violence
HESI Concepts: Health Policy/Systems – Health Care Law, Violence
References: Giddens, J. (2013). Concepts for nursing practice. (1st ed., p. 354.). St. Louis: Mosby.
Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 565-566). St Louis: Mosby.
Awarded 3.0 points out of 4.0 possible points.
13.ID: 8
The nurse is meeting with an older client who was brought into the health care facility for evaluation. According to the family member, the client has lost a large amount of weight recently and does not eat much. Which actions would be the most important for the nurse to take? Select all that apply. A. Assess the client's eyesight. Correct B. Question the client about urinary habits. C. Obtain a list of the client's medications. Correct D. Determine the fit of the client's dentures. Correct E. Assess the client for mental status changes. Correct
Rationale: Older adults in the community or in any health care setting are most at risk for poor nutrition. The nurse should review the medical history to determine the possibility of increased metabolic needs or nutritional losses, chronic disease, trauma, recent surgery of the gastrointestinal tract, drug and alcohol abuse, and recent significant weight loss. Each of these conditions can contribute to malnutrition. As part of a thorough assessment, the nurse should assess the client's eyesight. Clients with poor vision are often not able to drive to obtain groceries or cook for themselves. The nurse should also obtain a list of the client's medications, both prescription and over-the-counter. Certain medications can alter the taste perception and decrease the desire to eat. It is also important for the nurse to determine the fit of the client's dentures. Poor fitting dentures can lead to painful sores, which lead to a decrease in food intake. The nurse should also include an assessment of the client's mental status, observing for behavoir that may be abnormal for the client. Utilizing the family member's knowledge of the client's typical behavior will be important in the treatment of this client. While the client's urinary status is important to assess, it is not the most important action for the nurse to take at this time because it is not directly related to weight loss.
Test-Taking Strategy: Focus on the strategic words, “most important”. Next, determine which actions would help the nurse determine the cause of the client’s weight loss. Eliminate option 2, because questioning the client’s urinary habits would not be directly related to determining the cause of weight loss. Review: Older Adult Nutrition.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity.
Integrated Process: Nursing Process/Implementation.
Content Area: Nutrition
Giddens Concepts: Clinical Judgment,
Nutrition
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Metabolism - Nutrition
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1341). Philadelphia: Saunders.
Awarded 3.0 points out of 4.0 possible points.
14.ID: 1
The nurse is caring for a malnourished client with dementia and a history of rheumatoid arthritis, and is creating a plan of care for the client’s nutrition. Which nursing actions are most appropriate for increasing the client's caloric intake? Select all that apply. A. Provide pain medications as needed. Correct B. Play soft, calming music during mealtimes. Correct C. Serve the food at the appropriate temperature. Correct D. Provide the client with six small meals per day. Correct E. Encourage the client to eat quickly, to prevent fatigue.
Rationale: Malnutrition results from inadequate nutrient intake, increased nutrient losses, and increased nutrient requirements. Inadequate nutrient intake can be linked to poverty, lack of education, substance abuse, decreased appetite, and a decline in functional ability to eat independently, particularly in older adults. In order to support the client, the nurse should provide pain medication as needed so that the client is comfortable during meal times. The nurse can make mealtime positive by providing a quiet environment, which is conducive to eating. Soft music may calm those with advanced dementia or delirium. It is important that the nurse serve the client’s food at the appropriate temperature, in order to make the food appealing to the client. Arranging for the client to eat six small meals per day, instead of three large meals, may increase the client’s desire to eat, and prevent the client from being overwhelmed by a large amount of food at each meal. It is important that the nurse avoid rushing the client through a meal, but allow as much time as needed.
Resource: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia: Saunders.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Eliminate option 5, because this action would likely cause the client to take in fewer calories. Review: Malnutrition.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Nutrition
Giddens Concepts: Health Promotion,
Nutrition
HESI Concepts:Health, Wellness, and Illness – Health Promotion, Metabolism - Nutrition
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1340, 1343). Philadelphia: Saunders.
Awarded 3.0 points out of 4.0 possible points.
15.ID: 4
The nurse is educating a client on obesity. Which statements by the client indicate a need for further teaching? Select all that apply. A. "Type II diabetes is a complication of obesity". B. "I will likely develop obstructive sleep apnea". C. "Physical inactivity is one of the causes of obesity". D. "My heart and lungs are mildly affected by obesity". Correct E. "It is unlikely that I will develop peripheral artery disease". Correct
Rationale: Obesity refers to an excess amount of body fat when compared with lean body mass. After receiving education from the nurse, the client should be able to state that complications and risks of obesity such as type II diabetes and peripheral artery disease and other cardiovascular and respiratory system complications such as obstructive sleep apnea. It is also important that the nurse discuss the causes of obesity, which include physical inactivity. Encouraging the client to exercise 20 minutes per day can decrease the risk of obesity and life threatening illnesses.
Test-Taking Strategy: Focus on the strategic words, “need for further teaching.” Think about the physiological effects of obesity to assist in answering correctly. Eliminate statements that show that the teaching has been effective, such as options 1, 2, and 3. These options demonstrate that the client has an adequate understanding of the consequences of obesity. Options 4 and 5 are incorrect, showing the client would benefit from further education from the nurse. Review: Obesity.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Client Education, Nutrition,
HESI Concepts: Health, Wellness, and Illness: Nutrition/ Teaching and Learning:Patient Education
Reference: Ignatavicius, D & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1350). Philadelphia: Saunders.
Awarded 2.0 points out of 2.0 possible points.
16.ID: 0
The nurse is attending a teaching sessionatt on communicating with the ill child. Which statement by the nurse indicates that the teaching has been effective? Select all that apply. A. "I will strive to maintain honesty and trust with each child". Correct B. "Children are often reluctant to ask questions, when they fear the answers". Correct C. "Providing as much information as possible will help ease the child's fears". Incorrect D. "Complete honesty may cause problems for some family and staff members". Correct E. "To prevent misunderstandings, I should ask the child to explain what is known". Correct
Rationale: Communication is the most important factor in establishing a good relationship with the child and family. The nurse caring for the ill child should strive to make the child feel comfortable, as well as decrease any fears that the child may have. After listening to the lecture on communication with the ill child, the nurse should understand the need to strive to maintain honesty and trust with each child. Lack of honesty and trust can hinder care and leave the child feeling frightened. The nurse should also understand that children often are reluctant to ask questions when they fear the answers. The nurse should keep the child informed, while clarifying any questions the child has. Clarifying questions can help the nurse avoid providing more information than the child wants or can handle emotionally. Providing too much information may be overwhelming and frightening to the child. It may also inhibit future questions and interaction with the nurse. It is important for the nurse to consider that not everyone agrees with complete honesty; at times, parents may directly ask the nurse to withhold information from the child. It is important that the nurse maintain honesty, using terms that the parents agree upon. One of the most important aspects of communicating with a child is to have the child explain what is already known to them about their illness. The nurse can then answer questions accordingly without overwhelming the child with information.
Test-Taking Strategy: Focus on the strategic word, “effective.” Think about the developmental process and the effects illness can cause Determine which statements show that the nurse has an understanding of the topic, communication with the ill child. Eliminate option 3, because this statement indicates that more education is needed. Review: Communication techniques.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Child Health
Giddens Concepts: Caregiving, Communication..
HESI Concepts: Communication, Developmental
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children
(10th ed. pp. 92-94). St Louis: Mosby.
Awarded 1.0 points out of 4.0 possible points.
17.ID: 6
A client is being assessed for post-partum depression. Which actions by the client would indicate a need for follow-up by the nurse? Select all that apply. A. Not responding to the infant’s cries. Correct B. Crying after talking with spouse on the phone. Correct C. Stating that family was not supportive of the pregnancy. Correct D. Making statements about being fat and unattractive now. Correct E. Stating that that the infant latched on properly during a feeding.
Rationale: The weeks following the birth are a time of vulnerability to psychiatric disorders, such as depression for many women, causing significant distress for the mother, disrupting family life, and, if prolonged, negatively affecting the child's emotional and social development. Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. Such conditions can interfere with attachment to the newborn and family integration, and some may threaten the safety and well-being of the mother, the newborn, and other children. It is important that the nurse frequently assess the client for post-partum depression. Ignoring the infant’s cries should alert the nurse that further assessment is needed. Crying after talking with a spouse of the phone could indicate a problem at home. Statements of non-supportive family members need to be addressed by the nurse, for the safety and well-being of the client and infant. The nurse should also address the client’s statements about body image, educating the client about what is normal and what is not normal in the post-partum period. Stating that the infant latched on during a feeding is a positive action and would not indicate the need for further assessment.
Test-Taking Strategy: Focus on the strategic words, “need for follow-up.” Determine which actions by the client indicate that the client could be experiencing post-partum depression. Eliminate option 5, because this statement is positive and does not indicate that the client is experiencing postpartum depression. Review: Post-partum depression.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., pp. 748-749). St. Louis: Elsevier.
Awarded 3.0 points out of 4.0 possible points.
18.ID: 4
The nurse is evaluating a client who is four weeks post-partum. Which statement by the client would indicate a need for intervention? Select all that apply. A. "I feel like giving up." Correct B. "My husband never helps me with the baby." Correct C. "My baby will not stop crying and I can't take it anymore." Correct D. "I wish I could get more than four hours of sleep at a time." E. "My milk has come in and my baby is nursing every 2 hours."
Rationale: Post-partum depression is an intense and pervasive sadness with severe and labile mood swings and is more serious and persistent than postpartum blues. Intense fears, anger, anxiety, and despondency that persist in the new mother past the baby's first few weeks of life are not a normal part of postpartum blues. These symptoms rarely disappear without professional help. The nurse should be aware of statements that could place the well-being of the client and infant at risk, such as wanting to give up or reporting lack of support from a spouse. An inconsolable infant should be evaluated to determine the cause of crying. Most clients in the post-partum period struggle with sleep due to the infant waking up for feedings, which is a normal part of infant life in the first few weeks. An infant who nurses every two hours at four weeks of life is a normal finding and does not require an intervention.
Test-Taking Strategy: Focus on the strategic words, “need for intervention.” Determine which actions by the client indicate that the nurse should intervene. Eliminate options 4 and 5, because these statements are positive and do not indicate a need for the nurse to intervene. Review: post-partum depression.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity.
Integrated Process: Nursing Process/Assessment
Content Area: Maternity
Giddens Concepts: Clinical Judgment, Mood and Affect
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Mood and Affect
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 749). St. Louis: Elsevier.
Awarded 2.0 points out of 3.0 possible points.
19.ID: 1
The client is being discharged home after the delivery of a healthy infant. The nurse is educating the client on how to prevent postpartum depression. Which activities are the most appropriate for the nurse to suggest? Select all that apply. A. Exercise on a regular schedule Correct B. Eat a healthy, well-balanced diet Correct C. Try to sleep when the baby sleeps Correct D. Don’t overcommit yourself to activities that will be tiring Correct E. Stay home with the baby as much as possible, to promote bonding Incorrect
Rationale: The postpartum nurse must observe the new mother carefully for any signs of tearfulness and conduct further assessments as necessary. Nurses must discuss post-partum depression to prepare new parents for potential problems in the postpartum period. The nurse can provide activities and recommendations to improve the client’s health and well-bring. Exercising on a regular basis will help the client feel better and maintain physical health, as well as eating a healthy diet. The nurse should also suggest avoiding over commitment to activities that will tire the new mother. The nurse should advise the client to sleep when the infant sleeps. While it is important for the client to bond with the infant, the client should not be isolated from friends and family.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which activities will assist the client in preventing post-partum depression. Eliminate option 5 because it isolates the client from others and could lead to post-partum depression. Review: Prevention of post-partum depression.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity.
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health, Wellness, and Illness – Health Promotion,
Teaching and Learning/Patient Education
Reference: Lowdermilk, D., Perry, S., Cashion, K., & Alden, K. (2016). Maternity & Women’s Health Care (11th ed., p. 748). St. Louis: Elsevier.
Awarded 2.0 points out of 4.0 possible points.
20.ID: 0
The nurse is preparing to discharge a child who was treated in the emergency department. Which should the nurse consider when planning medication discharge instructions for the client's parents? Select all that apply. A. Provide the child's parents with a simple dosing schedule. Correct B. Create a medication schedule that fits the parent’s lifestyle. Correct C. Assist the child’s parents in obtaining the medication at an affordable cost. Correct D. Ensure that the child's family is able to read the written discharge instructions. Correct E. Refer the family to the pharmacist with questions about medication side effects. Incorrect
Rationale: Medicating infants and children is an important nursing responsibility. The nurse plays a key role in administering medications, supporting the child and family during the experience, and teaching the child and parents about pharmacologic aspects of the child's care. The nurse should not only coordinate the child's care, but also the discharge process. It is important that the nurse create a medication schedule that fits the family’s lifestyle and provide the family with a simple dosing chart. This helps to ensure that the childreceives proper medication dosing and prevents medication errors. The nurse should consider cost of prescribed medications and providing the family with resources as needed. During the discharge process, the nurse should verify that the family can read the written discharge instructions and answer any questions about the prescribed medications, including side effects.
Test-Taking Strategy: Focus on the subject, “discharge planning“ and “medication instructions.” The discharge process is often complex, the nurse should take actions to simplify this as much as possible. Eliminate options 5, because the nurse should review medications and side effects with the family during the discharge. Although the pharmacist is an excellent resource, it is the nurse’s responsibility to teach about the medication. Review: Discharge teaching.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Child Health
Giddens Concepts: Care Coordination, Client Education
HESI Concepts:
Collaboration/Managing Care – Care Coordination, Teaching and Learning/Patient Education
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 932-933). St Louis: Mosby.
Awarded 1.0 points out of 4.0 possible points.
21.ID: 0
The nurse is preparing to administer blood to a client. Which actions by the nurse are the most appropriate before administration of the blood? Select all that apply. A. Assess laboratory values. Correct B. Obtain and assess vital signs. Correct C. Evaluate the client’s venous access. Correct D. Identify the client by room number and bed. E. Check the health care provider’s prescriptions with another nurse. Correct
Rationale: Preparation of the client for transfusion therapy is critical, and institutional blood product administration procedures must be carefully followed. Before administering any blood product, review the agency's policies and procedures. The nurse should take care to ensure that the client is adequately prepared to receive the blood. This is accomplished by assessing the client’s laboratory values, in order to determine the client’s need for intervention. The nurse should be aware of the health care facilities policies and procedures regarding blood administration. The nurse should also obtain and assess the client’s vital signs, prior to blood administration. This is completed so that the nurse can detect any change from the client’s baseline during the administration. The client’s venous access should be assessed prior to the blood administration, ensuring that at least a 20 gauge IV is in place and patent. Checking the health care provider’s prescription with another nurse is a crucial step that must be completed. The nurse should not simply identify the client by room number and bed. The nurse must follow the policies and procedures set by the health care facility for safe blood administration.
Test-Taking Strategy: Focus on the strategic words, “most appropriate.” Determine which actions should be completed by the nurse prior to blood administration. Eliminate option 4, because this step is unsafe and could lead to client harm. The nurse should identify the client using appropriate and safe identifier guidelines. The nurse should take steps to provide for client safety during blood administration. Review: Blood Administration.
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Analysis
Content Area: Blood Administration
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 822). St. Louis: Saunders.
Awarded 3.0 points out of 4.0 possible points.
22.ID: 9
The nurse is evaluating a medication prescription written by the health care provider. Which pieces of information should the nurse verify has been included in the prescription? Select all that apply. A. The specific dosage Correct B. The client’s home address C. The generic medication name Correct D. The length of time for the administration Correct E. The route and frequency of administration F. Correct
Rationale: Medication safety is extremely important in all health care settings. The Joint Commission publishes new and updated National Patient Safety Goals (NPSGs) every year. The nurse should be prepared to evaluate each medication prescription to ensure that the proper information is included, and intervene when necessary to provide safe client care. The information should include: the specific dosage, generic drug name, length of drug administration and route and frequency of administration. The medication prescription does not need to include the client’s home address.
Test-Taking Strategy: Focus on the subject, “verifying the required information in a medication prescription.” Determine what information is pertinent for safety. Eliminate option 2, because the client’s home address is not considered pertinent information in this situation. Review: Components of a medication prescriptions
Level of Cognitive Ability: Analyzing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Assessment
Content Area: Fundamentals of Care: Safety
Giddens Concepts: Care Coordination, Safety
HESI Concepts: Care Coordination, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques
(8th ed., pp. 489-490). St. Louis: Mosby.
Awarded 3.0 points out of 4.0 possible points.
23.ID: 1
The nurse is caring for a postoperative client with a patient controlled analgesia (PCA) pump. When creating the client’s plan of care, which opiate-induced side effects should the nurse monitor? Select all that apply. A. Sedation Correct B. High blood glucose C. Increased appetite D. Nausea and vomiting Correct E. Elevated cardiac enzymes
Rationale: Patient-controlled analgesia (PCA) is a common way to address the problem of inadequate analgesia by allowing the client to control the dosage of opioid received. This approach to pain control can improve pain relief and increase client satisfaction. It can also decrease the amount of opioid consumption per day when compared with nurse-administered intermittent dosing methods. When creating the plan of care, the nurse should anticipate opiate-induced side effects, and be prepared to monitor for them and manage them. These side effects include sedation, nausea, and vomiting. High blood glucose, increased appetite and elevated cardiac enzymes are not typical opiate-induced side effects.
Test-Taking Strategy: Focus on the subject, “opiate-induced side effects.” Think about the physiological effects of an opiate on the body to assist in answering correctly. Review: Opiate-induced side effects.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Care Coordination, Pain
HESI Concepts: Care Coordination, Pain
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 43-44, 271). St. Louis: Saunders.
Awarded 2.0 points out of 2.0 possible points.
24.ID: 2
The nurse is providing discharge instructions to a client with rheumatoid arthritis who is taking leflunomide. Which instructions should the nurse give to the client? Select all that apply. A. “You may lose your hair.” Correct B. “It is ok to drink alcohol.” C. “Diarrhea is a common side effect.” Correct D. “It has been shown that leflunomide can cause birth defects.” Correct E. “Leflunomide is a potent medication that is generally tolerated.” Correct
Rationale: Medication therapy and nonpharmacologic interventions are used to manage systemic inflammation and joint pain. The expected outcome is that the disease goes into remission and its progression slows. When creating and providing discharge instructions, it is important that the nurse include accurate information. The nurse should educate that the client that hair loss and diarrhea are possible. Women of child-bearing age should remain strict with birth control, as the medication can cause birth defects. The client should be educated that while leflunomide is a potent medication, it is generally well tolerated.
Test-Taking Strategy: Focus on the subject, “discharge instructions for the client receiving leflunomide.” Use general medication guidelines to assist in answering correctly. Remember alcohol should not be consumed if the client is taking medications. Review: Discharge instructions for leflunomide.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Client Education, Safety
HESI Concepts: Teaching and Learning/Patient Education, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 308, 310). St. Louis: Saunders.
Awarded 3.0 points out of 4.0 possible points.
25.ID: 3
The nurse is caring for a client who has been admitted to the intensive care unit with acute pulmonary edema. After assessing the client, the nurse administers furosemide as prescribed. Which actions by the nurse are the most important after administering the medication? Select all that apply. A. Assess lung sounds Correct B. Measure urine output Correct C. Obtain and monitor vital signs Correct D. Document the client’s meal intake E. Assess the client for pitting edema Incorrect
Rationale: The client with pulmonary edema usually needs aggressive treatment and continuous cardiac monitoring. The nurse should be prepared to assess the client and manage the pulmonary edema efficiently. The most important interventions for the nurse to take after administration of the medication include: assessing the client lung sounds and vital signs and measuring the urine output. These interventions will assist in evaluating client status and response to treatment and alert the nurse to any deterioration in the client’s health. Documenting the client’s meal intake and assessing for pedal edema are not the most important actions to take after administering the medication.
Test-Taking Strategy: Focus on the strategic words, “most important.” Recall that furosemide is a diuretic and think about its expected effects in the treatment of pulmonary edema. Review: furosemide and pulmonary edema
Level of Cognitive Ability: Synthesizing
Client Needs: Physiological Integrity.
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Gas Exchange, Perfusion
HESI Concepts: Oxygenation/Gas Exchange, Perfusion
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 689, 715). St. Louis: Saunders.
Awarded 2.0 points out of 3.0 possible points.
26.ID: 7
The nurse preceptor is orienting a new nurse on an acute medical-surgical unit and educating the nurse on peripherally inserted central catheters (PICCs). Which statement by the new nurse indicates an understanding of a PICC? Select all that apply. A. “The tip of the PICC line sits in the superior vena cava.” Correct B. “Insertion of the PICC line occurs in the operating room.” Incorrect C. “PICCs can accommodate infusions of all types of therapy.” Correct D. “PICCs with a lumen size of 14 Fr or larger can be used for blood sampling.” Correct E. “PICCs are the most appropriate for client’s who require short-term antibiotics.”
Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubitcal fossa (inner aspect of the bend of the arm) or the middle of the upper arm. When educating the new nurse on the purpose and use of PICC lines, the nurse preceptor should discuss the placement of the PICC line, including where the PICC line is placed in the body. The nurse should explain that PICC line insertions are typically done at the client’s bedside, by a nurse with specialized training. PICC lines can accommodate infusions of all types of therapy because the tip sits in the superior vena cava, where the rapid blood flow quickly dilutes the infusion. The nurse preceptor should include information about blood sampling, such as only sampling blood from a PICC line with a lumen size of a 14 Fr or larger. The new nurse should also recognize that PICC lines are often used for client’s who require long-term antibiotics, in order to protect the vein and skin tissue.
Test-Taking Strategy: Focus on the subject, “an understanding about a PICC line.” It is necessary to know about these types of infusion catheters in order to answer correctly. Thinking about the anatomical location of the tip of the catheter may assist in answering correctly. Review: PICC lines.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Intravenous Administration
Giddens Concepts: Safety, Teaching and Learning
HESI Concepts: Teaching and Learning/Patient Education, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 193-194). St. Louis: Saunders.
Awarded 2.0 points out of 3.0 possible points.
27.ID: 9
The nurse is assigned to care for a client who needs an intravenous (IV) catheter inserted and will receive an IV infusion of a vesicant medication. When creating a plan of care for the client, which interventions should the nurse include in the plan? Select all that apply. A. Assess the skin integrity Correct B. Monitor the site frequently Correct C. Place the IV at an area of flexion D. Educate the client about the signs and symptoms of infiltration Correct E. Understand the vesicant potential before administering the infusion Correct
Rationale: It is important that the nurse take time to prepare for the IV infusion before administering any medication. The nurse should assess the client’s skin integrity prior to selecting an IV site. The nurse should avoid placing the IV at an area of flexion, such as in the antecubital space, or any other space that will limit or prevent the client’s range of motion. The nurse should plan to monitor the site frequently for signs of infiltration. The nurse should also educate the client about the signs and symptoms of infiltration and inform the client to alert the if any signs such as discomfort occur. Prior to administering the infusion, the nurse should understand the vesicant potential.
Test-Taking Strategy: Focus on the subject, “creating a plan of care for a client receiving an IV infusion of a vesicant medication.” Remember that the nurse needs to know what is being administered before administration. Next remember that assessing and monitoring is always a part of a plan of care as is client education. Eliminate option 3 noting the words “area of flexion.” Review: Skin Integrity.
Level of Cognitive Ability: Creating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Intravenous Administration
Giddens Concepts: Health Care Quality, Tissue Integrity
HESI Concepts: Quality Improvement/Health Care Quality, Tissue Integrity
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 191-192, 379). St. Louis: Saunders.
Awarded 4.0 points out of 4.0 possible points.
28.ID: 0
The nurse is preparing to administer oral potassium chloride to a client. What should the nurse keep in mind about this medication? Select all that apply. A. Potassium has a strong, unpleasant taste. Correct B. Potassium can only be mixed with water. Incorrect C. Potassium may be taken in a liquid or solid form. Correct D. Potassium chloride can cause nausea and vomiting. Correct E. Potassium may be given as an intramuscular (IM) injection.
Rationale: Interventions for hypokalemia aim to determine the cause, prevent further potassium loss, increase serum potassium levels, and ensure client safety. When preparing to administer potassium to the client, the nurse should keep in mind that potassium has a strong, unpleasant taste that is often difficult to mask. The client should be made aware of this beforehand. Oral potassium may be taken as either a liquid or a solid. This is important to keep in mind for clients who have difficulty swallowing large pills. The nurse should be aware that potassium chloride can cause nausea and vomiting, therefore it is recommended that the client take the medication with food. Potassium can be mixed with a variety of liquids, in order to make the medication more pleasant for the client. Potassium should never be administered IM, because it is a severe tissue irritant.
Test-Taking Strategy: Focus on the information in the question, “administration of oral potassium.” Eliminate option 2 because of the closed-ended word “only.” Noting that the question is asking about oral administration will assist in eliminating option 5. Review: Potassium chloride
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Lilley, L., Rainforth Collins, S., Harrington, S., & Snyder J. (2014). Pharmacology and the nursing process (7th
ed., pp. 487-488). St. Louis: Mosby.
Awarded 0.0 points out of 3.0 possible points.
29.ID: 8
The nurse is caring for a client with a latex allergy. Upon entering the client’s room, the nurse should plan to take which action as the priority? A. Perform a skin assessment B. Perform a physical assessment C. Ask if the client needs pain medication D. Remove the banana from the client’s breakfast tray E. Correct
Rationale: A sensitivity or allergy to certain substances alerts the nurse to other possible cross allergies. The nurse should be aware of this and prevent allergic reactions whenever possible. The nurse should know that the client with an allergy to latex, may also be allergic to bananas. The priority action that the nurse should plan to take when entering the client’s room, is to remove the banana from the client’s breakfast tray. The other actions can be completed once the risk of allergic reaction has been removed.
Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question, that the client has a latex allergy. It is necessary to know crosssensitivities to answer correctly. Eliminate options 1, 2, and 3, because these actions can safely wait until the banana has been removed from the client’s breakfast tray. Also note that options 1 and 2 are comparable or alike and can be eliminated. Review: latex allergy
Level of Cognitive Ability: Synthesizing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management: Prioritizing
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., pp. 402-403). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
30.ID: 9
The nurse has been assigned to care for an older client with a hip fracture who had surgical repair. After receiving report, the nurse learns that the health care provider has prescribed meperidine for pain management. Which action should the nurse take first? A. Prepare the medication B. Verify the dosage of meperidine Incorrect C. Assess the client’s pain score before administration. D. Clarify the medication prescription with the health care provider. Correct
Rationale: After fracture treatment, the client often has pain for a prolonged time during the healing process. The health care provider commonly prescribes opioid and non-opioid analgesics, anti-inflammatory drugs, and muscle relaxants. The nurse should immediately recognize that meperidine is contraindicated for the older client because it has toxic metabolites that can cause seizures and other complications. The first step the nurse should take is to clarify the prescription with the health care provider. The other steps should not be done.
Test-Taking Strategy: Focus on the strategic word, “first” and focus on the data in the question and that the client is an older client. Determine which step the nurse should take first when receiving the medication order. Eliminate options, 1, 2, and 3, because this medication should not be given to an older client. Review: contraindications for meperidine
Level of Cognitive Ability: Synthesizing
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management: Prioritizing
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety
Reference: Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing: Patient-centered collaborative care. (8th ed., p. 42). St. Louis: Saunders.
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