1. 1.ID: 22572488317
A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension.
Which findings denote adverse effect... [Show More] s of the medication? Select all that apply.
A. Constipation
B. Tall T waves Correct
C. Hyporeflexia
D. Shallow respirations
E. Prolonged PR interval Correct
F. Hyperactive bowel sounds Correct
Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can
cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves,
widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular
manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats.
Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in
hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia.
Test-Taking Strategy: Knowledge of the subject, that spironolactone is a potassium-sparing
diuretic, will assist you in determining that hyperkalemia is an adverse effect of the medication.
Recalling the manifestations of hyperkalemia will direct you to the correct options. Also, note
that the incorrect options are comparable or alike in that they indicate a slowed body response
or function.
Review: the adverse effects of spironolactone and the manifestations of.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Pharmacology
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision Making-Clinical Judgment-Critical Thinking, Fluid &
Electrolyte
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp.
1125-1127) St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
2. 2.ID: 22572488314
A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease
(COPD) who is experiencing a loss of appetite and complains of feeling “too full to eat.” The
nurse realizes the instructions were effective if the client verbalizes making which
changes? Select all that apply.
A. Avoid drinking fluids before and during meals Correct
B. Eat a variety of dark-green vegetables, such as broccoli
C. Have snacks, such as crackers and cheese, between meals
D. Select foods that are easy to chew and are not gas forming Correct
E. Consume high-calorie drinks, such as milkshakes, between meals
Rationale: COPD is a progressive and irreversible condition characterized by diminished
inspiratory and expiratory capacity of the lungs. Instruct the client who complains of feeling too
full to eat, to avoid drinking fluids before and during the meal. Dry foods such as crackers
stimulate coughing; foods such as milk and chocolate may increase the thickness of saliva and
secretions. Cheese is constipating and should also be avoided by the client. The nurse should
also teach the client about foods that are easy to chew and do not encourage the formation of
gas; for this reason, broccoli, which is a gas-forming food, should be avoided.
Test-Taking Strategy: Use knowledge of the subject, dietary measures for a client with COPD
to assist with the process of elimination. Recalling that milk may increase the thickness of
saliva will assist you in eliminating the option that encourages the consumption of milkshakes.
Eliminate the option in which the consumption of broccoli is encouraged, because it is a gasforming food. To select from the remaining options, note the strategic words “too full to eat” in
the question and the option that encourages the client to avoid fluids before and during meals;
this will direct you to the correct answers.
Review: dietary measures for the client with COPD
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Respiratory
Giddens Concepts: Gas Exchange, Nutrition
HESI Concepts: Oxygenation-Gas Exchange, Metabolism
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 595-596). St. Louis:
Mosby.
Awarded 50.0 points out of 100.0 possible points.
3. 3.ID: 22572488311
A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV infection. Fortyeight hours after administration, the nurse checks the test site (see image).
The nurse documents the result of the test as:
A. Positive Correct
B. Negative
C. Insignificant
D. Indeterminate
Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis (TB) infection.
A reaction measuring 5 mm or more in diameter is considered positive in a client with HIV
infection. A reaction measuring 10 mm or more in diameter is considered positive in a nonimmunosuppressed client. In this instance, the area of induration measures 9 mm, indicating a
positive reaction. A positive reaction does not mean that active disease is present, but it does
indicate exposure to TB or the presence of inactive (dormant) disease.
Test-Taking Strategy: Use the process of elimination. Eliminate the comparable or alike
options (negative and insignificant). To select from the remaining options, note that the client
has HIV, which will assist in directing you to the correct option. An area of induration is
present, so the test results are not indeterminate.
Review: the tuberculin skin test and the procedure for interpreting the results
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Respiratory
Giddens Concepts: Immunity, Infection
HESI Concepts: Immunity, Infection
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 494, 530). St. Louis:
Mosby.
Awarded 100.0 points out of 100.0 possible points.
4. 4.ID: 22572488308
A nurse is interpreting a central venous pressure (CVP) reading from a client in whom right
ventricular failure has been diagnosed. From this diagnosis, the nurse would expect that
the most likely result is a pressure of:
A. 4 cm H2O
B. 8 cm H2O
C. 11 cm H2O
D. 14 cm H2O Correct
Rationale: CVP measurements are used to monitor blood volume and the adequacy of venous
return to the heart. The CVP measures pressures from the right atrium or central veins. The
normal CVP is 7 to 12 cm H2O. An increased CVP reading may indicate right ventricular
failure. A low CVP reading may indicate hypovolemia. A reading of 4 cm H2O is low. Readings
of 8 and 11 cm H2O are normal. A reading of 14 cm H2O is increased.
Test-Taking Strategy: Focus on the data in the question, the client’s diagnosis. Thinking
about the pathophysiology of right ventricular failure and recalling the normal CVP reading will
direct you to the correct option.
Review: the normal CVP reading and the expected findings in right ventricular failure
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Cardiovascular
Giddens Concepts: Fluids and Electrolytes, Perfusion
HESI Concepts: Fluid & Electrolyte, Perfusion
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 1608-1609). St. Louis:
Mosby.
Awarded 100.0 points out of 100.0 possible points.
5. 5.ID: 22572488305
A nurse is caring for a client who has just undergone thyroidectomy. Which technique is
the best way for the nurse to assess the surgical site for bleeding?
A. Asking the client whether the dressing feels wet
B. Looking for moisture on the top of the dressing
C. Removing and replacing the dry sterile dressing every 2 hours
D. Checking for moisture on the back of the dressing over the client’s neck and
shoulders Correct
Rationale: Thyroid surgery may be complicated by hemorrhage, respiratory distress,
parathyroid gland injury (resulting in hypocalcemia and tetany), damage to the laryngeal nerves,
and thyroid storm. Hemorrhage is most likely during the 24 hours after surgery. If the client is
bleeding after surgery, gravity will cause the blood to seep down the sides of the dressing and
drain onto the underlying bed linens even as the top of the dressing remains clean and dry.
Asking the client whether the dressing feels wet and replacing the dry sterile dressing every 2
hours are not the best actions. Replacing the dressing frequently when it is not warranted could
also increase the risk of infection.
Test-Taking Strategy: Note the strategic word “best.” Recalling the anatomical location of the
surgical site will direct you to the correct option.
Review: care of the client after thyroidectomy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Perioperative Care
Giddens Concepts: Perfusion, Hormonal Regulation
HESI Concepts: Perfusion, Tissue Integrity
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patientcentered collaborative care. (7th ed., p. 1399). St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
6. 6.ID: 22572488302
A client who sustained a major burn injury is beginning to take an oral diet again. The nurse has
provided instructions on foods needed for wound healing and tissue repair. The nurse realizes
that further instructions are required if which between-meals items are selected by the client?
? Select all that apply.
A. Apple slices and skim milk Correct
B. Whole-milk shake and granola
C. Baked potato topped with cheese
D. Cheese and whole-wheat crackers
E. Cauliflower with low-fat ranch dip Correct
Rationale: To facilitate healing and meet continued high metabolic needs, the client with a
major burn should eat a diet high in calories, protein, and carbohydrates. This type of diet also
keeps the client in positive nitrogen balance. Foods such as milkshakes, granola, cheese, and
whole-wheat products are acceptable choices. Though fresh fruits and vegetables and skim milk
are high in nutrients, higher-calorie foods, including versions of dairy products prepared with
whole milk, are preferable in this situation.
Test-Taking Strategy: Focus on the subject, nutrition needed for wound healing and tissue
repair following a burn injury. This question is a negative event query, which calls for the
selection of the incorrect responses. Use your knowledge of the principles of nutrition in regard
to tissue healing to answer this question. Remembering that the burned client’s diet should be
high in calories, protein, and carbohydrates will assist you in answering correctly.
Review: the nutrition required for healing and tissue repair.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/ Evaluation
Content Area: Nutrition
Giddens Concepts: Nutrition, Tissue Integrity
HESI Concepts: Metabolism, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 467-468). St. Louis:
Mosby.
Awarded 0.0 points out of 100.0 possible points.
7. 7.ID: 22572488099
A client is found to have hypoparathyroidism. Which nutritional supplement does the nurse,
teaching the client about measures to manage the disorder, tell the client to take on a daily
basis?
A. Vitamin C
B. Phosphorus
C. Beta-carotene
D. Calcium carbonate with vitamin D Correct
Rationale: Hypoparathyroidism is an endocrine disorder in which parathyroid function is
decreased. The client with hypoparathyroidism is likely to have low calcium and high
phosphate levels and should consume a diet high in calcium but low in phosphorus.
Additionally, the generally used treatment is calcium supplementation (either as calcium
carbonate or calcium citrate) coupled with vitamin D supplementation. Vitamin C
supplementation is not a treatment measure for this disorder. Beta-carotene is incorrect, because
a client with hypoparathyroidism typically has an increased phosphorus level.
Test-Taking Strategy: To answer this question accurately, use knowledge of the subject,
hypoparathyroidism. Recall that the client with hypoparathyroidism is likely to have low
calcium and high phosphate levels. This will direct you to the correct option.
Review: the treatment measures associated with hypoparathyroidism.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Patient Education, Nutrition
HESI Concepts: Teaching and Learning-Patient Education, Metabolism
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 1206-1207). St. Louis:
Mosby.
Awarded 100.0 points out of 100.0 possible points.
8. 8.ID: 22572488096
A nurse participating in a free health screening at the local mall obtains a random blood glucose
level of 190 mg/dL (10.6 mmol/L) and a total cholesterol level of 210 mg/dL (5.4 mmol/L) in
an otherwise healthy client. What should the nurse tell the client to do next?
A. Seek treatment for diabetes mellitus
B. Ask the health care provider about starting insulin therapy
C. Consult with a nutritionist about foods that are high in cholesterol
D. Call his health care provider to have these values rechecked as soon as
possible Correct
Rationale: Adult diabetes mellitus may be diagnosed on the basis of symptoms (e.g.,
polydipsia, polyuria, polyphagia) or laboratory values. An abnormal glucose tolerance test, a
random plasma glucose level greater than 200 mg/dL (11.1 mmol/L), and a fasting plasma
glucose level greater than 140 mg/dL (7.8 mmol/L) on two separate occasions are all diagnostic
of diabetes mellitus. The total cholesterol should be less than 200 mg/dL (5.2 mmol/L).
Confirmation of this client’s results is needed to ensure appropriate diagnosis and therapy.
Test-Taking Strategy: The strategic word in the question is “next.” Eliminate the comparable
or alike options that the nurse makes a diagnosis or recommends a treatment. Choose correctly
between the remaining options by recalling that that follow-up with a health care provider is
required.
Review: Screening screening for diabetes and elevated cholesterol.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Endocrine
Giddens Concepts: Patient Education, Health Promotion
HESI Concepts: Teaching and Learning-Patient Education, Health Promotion
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 699-700). St. Louis:
Mosby.
Awarded 100.0 points out of 100.0 possible points.
9. 9.ID: 22572488027
Levothyroxine sodium is prescribed for a client with hypothyroidism, and the nurse provides
information to the client about the medication. The nurse realizes teaching was effective if the
client selects which symptom to report to the health care provider? Select all that apply.
A. Lethargy
B. Chest pain Correct
C. Palpitations Correct
D. Weight gain
E. Constipation
F. Rapid heart rate Correct
Rationale: The client taking levothyroxine sodium may have manifestations of hypothyroidism
if the dosage is inadequate or may experience manifestations of hyperthyroidism if the dosage is
too high. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the
heart, which may result in angina and cardiac dysrhythmias. The client should be instructed to
report chest pain, palpitations, or a rapid heart rate immediately. Lethargy, constipation, and
weight gain are symptoms of hypothyroidism, which should improve with medication therapy
(e.g., levothyroxine sodium).
Test-Taking Strategy: Use the process of elimination. Recalling the classic symptoms of
hypothyroidism, which the medication should relieve, will assist you in eliminating lethargy,
constipation, and weight gain. Also, note that the incorrect comparable or alike options that
reflect slowing of a body response or function.
Review: the client teaching points for levothyroxine sodium.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Hormonal Regulation, Safety
HESI Concepts: Metabolism , Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 697)
St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
10. 10.ID: 22572488024
A nurse is developing a plan of care for an older client with diabetic neuropathy of the lower
extremities resulting from type 2 diabetes mellitus. Which problem does the nurse recognize as
the highest priority for this client?
A. Change in body image
B. Increased risk for injury Correct
C. Increased risk of depression
D. Lower level of physical activity
Rationale: The client with diabetic neuropathy of the lower extremities has a diminished
sensation in the legs and feet. This client is at risk for tissue injury and for falls as a result of
this nervous system impairment. Therefore the highest priority nursing problem is increased
risk for injury. Increased risk of depression and change in body image are more psychosocial in
nature and, as such, are secondary needs. A lower level of physical activity may be a problem
but is not the priority.
Test-Taking Strategy: Focus on the subject, the consequences of diabetic neuropathy.
Use Maslow’s Hierarchy of Needs theory and note the relationship between the word
“neuropathy” in the question and “risk for injury” in the correct option.
Review: the consequences of diabetic neuropathy.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Adult Health/Endocrine
Giddens Concepts: Glucose Regulation, Tissue Integrity
HESI Concepts: Metabolism, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., pp. 1182-1183, 1186). St.
Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
11. 11.ID: 22572488021
The nurse is teaching a client with newly diagnosed diabetes mellitus who has been prescribed
NPH insulin how to recognize the signs of hypoglycemia. The client states that he must look for
certain signs and symptoms in the late afternoon, indicating to the nurse that he has understood
the instructions. What are these signs and symptoms? Select all that apply.
A. Shakiness Correct
B. Drowsiness
C. Blurred vision Correct
D. Increased thirst
E. Feelings of hunger Correct
F. Nausea and vomiting
Rationale: When the medication’s action peaks, the client is at risk of hypoglycemia if food
intake is insufficient. The nurse teaches the client to be alert for signs and symptoms of
hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold
sweats, headache, increased pulse, shakiness, and hunger. The other options are signs and
symptoms of hyperglycemia.
Test-Taking Strategy: Note the subject, the signs and symptoms of hypoglycemia. Recalling
the pathophysiology of hypoglycemia will direct you to the correct answers.
Review: the signs and symptoms of hypoglycemia and hyperglycemia.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health/Endocrine
Giddens Concepts: Patient Education, Glucose Regulation
HESI Concepts: Teaching and Learning-Patient Education, Metabolism
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 1175). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
12. 12.ID: 22572488018
Glargine insulin is prescribed for a client with type 1 diabetes mellitus. What does the nurse tell
the client about this type of insulin? Select all that apply.
A. It does not have a peak effect. Correct
B. It is usually given once daily, at bedtime. Correct
C. It usually has a 24-hour duration of action. Correct
D. It may be mixed in a syringe with regular insulin.
E. Its onset of action comes 4 hours after administration.
Rationale: Glargine insulin, a long-acting basal insulin analog, has an onset of action of 1 to 2
hours, with no peak effect, and a duration of action of more than 24 hours. It is usually given
once daily, preferably at bedtime. Glargine insulin may not be mixed in a syringe with other
insulin.
Test-Taking Strategy: Knowledge regarding the subject, glargine insulin, is required to answer
this question.
Review: characteristics of glargine insulin
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Patient Education, Glucose Regulation
HESI Concepts: Teaching and Learning-Patient Education, Metabolism
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 624
) St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered
collaborative care. (7th ed., p. 1431). St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
13. 13.ID: 22572488015
A client arrives in the emergency department after sustaining a chemical splash to the eye. The
nurse immediately flushes the eye with copious amounts of normal saline solution for 15
minutes and then tests the pH of eye, using litmus paper. The nurse should continue the saline
flushes until the pH test reads:
A. 7.28
B. 7.30
C. 7.40 Correct
D. 7.50
Rationale: First aid after a chemical burn to the eye consists of irrigation of the eye with
copious amounts of tap water for at least 5 minutes. As soon as the initial irrigation is complete,
the victim should be rushed to the nearest medical facility. On arrival, eye irrigation should be
resumed with water or normal saline for 15 to 20 minutes or until all invasive material is gone
and litmus paper reveals a pH of about 7.40. A quick test with litmus can be performed before,
during, and after irrigations to determine the pH and to ascertain whether the substance was acid
or alkaline. The normal body pH is 7.40.
Test-Taking Strategy: Knowledge that the normal body pH is 7.40 will direct you to the correct
option. pH values of 7.28 and 7.30 indicate acidic condition, whereas 7.50 indicates an alkaline
condition. Eliminate comparable or alike options that reflect a low pH [Show Less]
