HESI/Saunders Module 7: Basic Care and Comfort Exam Questions and Answers|
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A client is receiving intravenous meperidine hydrochloride as prescribed. For which
side/adverse effects does the nurse assess the client while the clientis receiving this
medication? Select all that apply.
a. Polyuria
b. Diarrhea
c. Tachycardia
d. Hypotension
e. Mental clouding c. Tachycardia
d. Hypotension
e. Mental clouding
Rationale: Side/adverse effects of meperidine hydrochloride include respiratory depression,
orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine
retention. The incorrect options are effects opposite those expected with meperidine
hydrochloride.
Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the
nurse monitor while the client is taking this medication? Select all that apply.
a. Volume of urine output
b. Strength of peripheral pulses
c. Ability to move the extremities
d. Frequency of bowel movements
e. Color, motion, and sensation of extremities a. Volume of urine output
d. Frequency of bowel movements
Rationale: Because urine retention may occur with the use of opioid analgesics, the nurse would
monitor the volume of the client's urine output. Because the client is also at risk for
,constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse
effects include hypotension and slowed respiration. The incorrect options are not specifically
associated with this medication.
A client requests the use of an alternative or complementary therapy to help control pain and
asks about the use of guided imagery. The nurse responds by telling the client that in this
technique, the clientwill experience which?
a. Become totally unaware of pain
b. Ignore the pain by focusing on the alternate activity
c. Alter pain perception though the influence of positive suggestion
d. Become less aware of pain by creating and then concentrating on a mental image d.
Become less aware of pain by creating and then concentrating on a mental image
Rationale: In guided imagery, the client creates a mental image and then concentrates on the
image, becoming less aware of pain and other stimuli. Hypnosis can help alter pain perception
through the influence of positive suggestion. Certain distraction techniques, such as music, can
help a client ignore pain. No alternative or complementary therapy will allow the client to
become totally unaware of pain.
A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this
will help the injury. The nurse hould provide the clent with which information about a cold
pack?
a. Reduces muscle tension
b. Dilates the blood vessels
c. Promotes muscle relaxation
d. Reduces blood flow to the extremity d. Reduces blood flow to the extremity
Rationale: The application of cold reduces blood flow through its vasoconstriction action and
eases localized pain. Cold also reduces the oxygen need of the tissues and promotes blood
coagulation at the site of injury. The incorrect options are the effects of heat application.
,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 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 nurse provides instructions to a client about the use of an electric heating pad. The nurse
determines that the client needs further instruction if the client makes which statement?
a. "I shouldn't lie on the pad."
b. "I'll avoid using the high setting."
c. "I can pin the pad around the affected area."
d. "I'll need to keep an eye on my skin for redness." c. "I can pin the pad around the affected
area."
Rationale: One conventional form of heat therapy is the electric heating pad. The nurse instructs
the client to avoid using the pad on the high setting and to never lie on the pad, because these
actions can result in burns. The client is also instructed not to insert a safety pin through the
pad, which could result in an electric shock. The client must check the skin frequently for
redness.
Which client does the nurse recognize as being at the greatest risk for injury resulting from the
use of heat or cold application?
, a. An older client
b. A client with renal calculi
c. A client with osteoporosis
d. A client with rheumatoid arthritis a. An older client
Rationale: Older clients have diminished sensitivity to pain and are therefore at great risk for
injury from heat or cold applications. Other clients at risk for injury are the very young; those
with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the
client with diabetes mellitus; and those who are confused or unconscious.
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 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.
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)?
Select all that apply.
a. A client who has undergone colectomy
b. A client with acute pancreatitis
c. A client who has undergone gastrectomy
d. A client with renal insufficiency
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A client is receiving intravenous meperidine hydrochloride as prescribed. For which
side/adverse effects does the nurse assess the client while the clientis receiving this
medication? Select all that apply.
a. Polyuria
b. Diarrhea
c. Tachycardia
d. Hypotension
e. Mental clouding c. Tachycardia
d. Hypotension
e. Mental clouding
Rationale: Side/adverse effects of meperidine hydrochloride include respiratory depression,
orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urine
retention. The incorrect options are effects opposite those expected with meperidine
hydrochloride.
Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the
nurse monitor while the client is taking this medication? Select all that apply.
a. Volume of urine output
b. Strength of peripheral pulses
c. Ability to move the extremities
d. Frequency of bowel movements
e. Color, motion, and sensation of extremities a. Volume of urine output
d. Frequency of bowel movements
Rationale: Because urine retention may occur with the use of opioid analgesics, the nurse would
monitor the volume of the client's urine output. Because the client is also at risk for
,constipation, the nurse would monitor the frequency of bowel movements. Other side/adverse
effects include hypotension and slowed respiration. The incorrect options are not specifically
associated with this medication.
A client requests the use of an alternative or complementary therapy to help control pain and
asks about the use of guided imagery. The nurse responds by telling the client that in this
technique, the clientwill experience which?
a. Become totally unaware of pain
b. Ignore the pain by focusing on the alternate activity
c. Alter pain perception though the influence of positive suggestion
d. Become less aware of pain by creating and then concentrating on a mental image d.
Become less aware of pain by creating and then concentrating on a mental image
Rationale: In guided imagery, the client creates a mental image and then concentrates on the
image, becoming less aware of pain and other stimuli. Hypnosis can help alter pain perception
through the influence of positive suggestion. Certain distraction techniques, such as music, can
help a client ignore pain. No alternative or complementary therapy will allow the client to
become totally unaware of pain.
A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this
will help the injury. The nurse hould provide the clent with which information about a cold
pack?
a. Reduces muscle tension
b. Dilates the blood vessels
c. Promotes muscle relaxation
d. Reduces blood flow to the extremity d. Reduces blood flow to the extremity
Rationale: The application of cold reduces blood flow through its vasoconstriction action and
eases localized pain. Cold also reduces the oxygen need of the tissues and promotes blood
coagulation at the site of injury. The incorrect options are the effects of heat application.
,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 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 nurse provides instructions to a client about the use of an electric heating pad. The nurse
determines that the client needs further instruction if the client makes which statement?
a. "I shouldn't lie on the pad."
b. "I'll avoid using the high setting."
c. "I can pin the pad around the affected area."
d. "I'll need to keep an eye on my skin for redness." c. "I can pin the pad around the affected
area."
Rationale: One conventional form of heat therapy is the electric heating pad. The nurse instructs
the client to avoid using the pad on the high setting and to never lie on the pad, because these
actions can result in burns. The client is also instructed not to insert a safety pin through the
pad, which could result in an electric shock. The client must check the skin frequently for
redness.
Which client does the nurse recognize as being at the greatest risk for injury resulting from the
use of heat or cold application?
, a. An older client
b. A client with renal calculi
c. A client with osteoporosis
d. A client with rheumatoid arthritis a. An older client
Rationale: Older clients have diminished sensitivity to pain and are therefore at great risk for
injury from heat or cold applications. Other clients at risk for injury are the very young; those
with open wounds; those with spinal cord injuries or peripheral vascular disorders, such as the
client with diabetes mellitus; and those who are confused or unconscious.
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 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.
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)?
Select all that apply.
a. A client who has undergone colectomy
b. A client with acute pancreatitis
c. A client who has undergone gastrectomy
d. A client with renal insufficiency
