1.ID: 22266446341 A nurse is providing information to a mother of a 1-year-old who has asked about
bladder-training her child. The nurse should provide
... [Show More] which information to the mother?
A. That a child cannot begin to control urination until
approximately the age of 24 months Correct
B. That her child is too young and that she should not yet be
worrying about it
C. That bowel training should be started immediately and then
begin bladder training in about 1 month
D. That she may start bladder training at any time
2.ID: 22266446734 A client with renal calculi is instructed to follow an alkaline ash diet. Which menu
choice by the client indicates to the nurse that the client understands the prescribed regimen?
E. Linguini with shrimp, tossed salad, and a plum
F. Chicken, potatoes, and cranberries
G. Spinach salad, milk, and a banana Correct
H. Peanut butter sandwich, milk, and prunes
3.ID: 22266441990 The nurse is assigned to care for four clients. Which client does the nurse expect is
likely to experience chronic pain?
I. A client with a leg fracture who is in skeletal traction
J. A client who has undergone appendectomy
K. A client with osteoarthritis Correct
L. A client with angina pectoris
4.ID: 22266441971 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?
M. Apply the cold compress for 20 minutes, and then apply a hot
compress for 20 minutes
N. Elevate the ankle and place cold compresses under and on top
of the ankle
O. Apply the cold compress to the ankle
P. Consult with the HCP before applying the cold
compress Correct
5.ID: 22266441974 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?
Q. Reduces muscle tension
R. Dilates the blood vessels
S. Promotes muscle relaxation
T. Reduces blood flow to the extremity Correct
6.ID: 22266446338 A client has been found to have a bladder infection. When planning care, which
area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney
infection?
U. Glomerulus
V. Urethra
W. Nephron
X. Ureterovesical junction Correct
7.ID: 22266447025
A nurse has administered a dose of furosemide to a client with diminished urine
output. How does the nurse BEST determine effectiveness?
Y. The client reports less thirst as compared with yesterday
Z. The client reports socks which seem less tight on the ankle
area
AA. The client’s weight remains stable, over the past two to three
days
BB. The client’s urine output is 1500 ml more than the fluid
intake Correct
Rationale: Furosemide works by inducing excretion of sodium, potassium and
chloride. Body fluid is also excreted. The best way to determine if the
medication is effective is if the urine output is more than the fluid intake. Thirst
is subjective, and not the best determinate of fluid status. Many clients can
detect a change in the tightness of their socks over the ankle area, but this is
subjective, not objective data. The client should lose some weight when
furosemide causes fluid and sodium excretion.
Test Taking Strategy: Note the strategic words “best determine
effectiveness”. Use data in the question (diminished urine output) and search
the options for related information regarding an increasing urine output.
Eliminate the comparable or alike options that depict non-objective ways of
determining effectiveness.
Review: effects of furosemide
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Elimination,Fluids and Electrolytes
HESI Concepts: Elimination, Fluid & Electrolyte
Awarded 100.0 points out of 100.0 possible points.
2. 8.ID: 22266441987
A nurse develops a plan of care for a postoperative client who is receiving
intravenous morphine sulfate every 4 hours as needed for pain.
Which priority intervention does the nurse include in the plan?
A. Administering the morphine sulfate around the clock
B. Encouraging oral fluid intake
C. Encouraging coughing and deep breathing Correct
D. Maintaining the client in a supine position
Rationale: Morphine sulfate can depress respiration and suppress the cough
reflex, putting the postoperative client at greater risk for atelectasis and
subsequent pneumonia. The client should be encouraged to cough and deepbreathe to prevent these postoperative complications. Keeping the client
supine is counterproductive and could lead to atelectasis. Adequate fluid intake
helps liquefy secretions, making their expulsion easier, but does not prevent
atelectasis unless coughing and deep breathing is also performed. Because
the medication is prescribed as needed, it would not be administered around
the clock.
Test-Taking Strategy: Note the strategic word “priority.” Also note that the
client has just undergone surgery and is receiving morphine sulfate. Use
the ABCs — airway, breathing, and circulation — to find the correct option.
Review: nursing considerations related to the use of morphine sulfate
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation/Gas Exchange, Safety
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook
2015. (p. 813) St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
3. 9.ID: 22266447013
A nurse is instructing a client about the foods that will acidify the urine and
inhibit the growth of microorganisms. Which foods does the nurse tell the client
are most likely to acidify the urine? Select all that apply.
A. Cabbage
B. Cranberries Correct
C. Broccoli
D. Apples
E. Plums Correct
F. Prunes Correct
Rationale: Meats, eggs, whole-grain breads, cranberries, plums, and prunes
increase urine acidity. These foods are metabolized into acid end-products that
eventually enter the urine. The incorrect options are not food items that will
acidify the urine.
Test-Taking Strategy: Note the strategic words, most likely. Focus on
the subject, foods that acidify the urine. Use your knowledge of the
metabolism of the foods identified in the options to direct you to the correct
options.
Review: foods that will acidify the urine.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Renal and Urinary
Giddens Concepts: Elimination, Nutrition
HESI Concepts: Elimination, Teaching and Learning-Patient Education
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical
nursing: Patient-centered collaborative care. (7th ed., p. 1494). St. Louis:
Saunders.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical
nursing: Assessment and management of clinical problems (9th ed., p. 1069).
St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
4. 10.ID: 22266446725
A client with heart failure and hypertension who has been admitted to the
hospital is unable to make own selections from the menu. Which meal does the
nurse select for the client’s supper on the day of admission?
A. Smoked ham, fresh carrots, boiled potato
B. Shrimp, baked potato, salad with blue cheese dressing
C. Turkey, baked potato, salad with oil and vinegar Correct
D. Hot dog in a bun, sauerkraut, baked beans
Rationale: Foods that are high in sodium should be limited in the diet of the
client with hypertension and heart failure. Foods in the meat group that are
higher in sodium include bacon, luncheon meat, chipped or corned beef, ham,
hot dogs, kosher meat, smoked or salted meat or fish, and a variety of shellfish.
These foods should be avoided or strictly limited for clients with hypertension.
Test-Taking Strategy: Focus on the subject, diet for the client with heart
failure and hypertension. Recalling that the client with hypertension and heart
failure needs to limit sodium in the diet. Eliminate the hot dog and smoked ham
first because they are highly processed meats. (Sauerkraut is also high in
sodium.) Eliminate the menu consisting of shrimp and salad with blue cheese
dressing next, because shellfish and commercial dressings are high in sodium.
Review: foods high in sodium
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Cardiovascular
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids & Electrolytes, Health Promotion
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., pp. 715, 777-778). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points [Show Less]