Module 7 Exam
1. 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
... [Show More] nurse should provide 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
Rationale: A child cannot control micturition voluntarily until he or she is
approximately 24 months old. A child must be able to recognize the feeling of
bladder fullness, to hold urine for 1 to 2 hours, and to communicate the sense
of urgency to an adult. Telling the mother that her child is too young and to not
be worrying about bladder training is a nontherapeutic response because it
provides false reassurance and places the mother’s issue on hold. Bowel
control develops before bladder control; however, 1 year of age is too early for
the mother to begin elimination training.
Test-Taking Strategy: Use therapeutic communication techniques to
eliminate the option that tells the mother that her child is too young and to not
be worrying about bladder training. To select from the remaining options, recall
the concepts related to growth and development and elimination, which will
direct you to the correct option.
Review: growth and development concepts related to elimination.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Elimination
Giddens Concepts: Development, Elimination
HESI Concepts: Developmental, Elimination
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M.
(2013). Fundamentals of nursing. (8th ed., p. 147). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
2. 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?
A. Linguini with shrimp, tossed salad, and a plumB. Chicken, potatoes, and cranberries
C. Spinach salad, milk, and a banana Correct
D. Peanut butter sandwich, milk, and prunes
Rationale: In an alkaline ash diet, all fruits are allowed except cranberries,
prunes, and plums. The incorrect options represent components of an acid ash
diet.
Test-Taking Strategy: Focus on the subject, foods allowed on an alkaline ash
diet. Knowledge of foods that are either included or restricted in an alkaline ash
diet is necessary to answer this question. Remembering that cranberries,
prunes, and plums are not allowed in an alkaline ash diet will direct you to the
correct option.
Review: the foods allowed in an alkaline-ash and an acid-ash diet.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Elimination, Nutrition
HESI Concepts: Metabolism, Teaching and Learning-Patient Education
Reference: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed.,
pp. 443-444). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
3. 3.ID: 22266441990
The nurse is assigned to care for four clients. Which client does the nurse
expect is likely to experience chronic pain?
A. A client with a leg fracture who is in skeletal traction
B. A client who has undergone appendectomy
C. A client with osteoarthritis Correct
D. A client with angina pectoris
Rationale: Chronic pain is associated with chronic disease. The pain is
prolonged, varies in intensity, and lasts longer than 6 months. The incorrect
options are clients who are likely to experience acute pain.
Test-Taking Strategy: Focus on the subject, chronic pain. Think about the
word “chronic and note that the correct option is the only one that identifies a
chronic problem.
Review: the characteristics of acute and chronic pain
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Vital Signs
Giddens Concepts: Caregiving, Pain
HESI Concepts: Assessment, ComfortReference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing:
Patient-centered collaborative care. (7th ed., p. 41). St. Louis: Saunders.
Awarded 100.0 points out of 100.0 possible points.
4. 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?
A. Apply the cold compress for 20 minutes, and then apply a hot
compress for 20 minutes
B. Elevate the ankle and place cold compresses under and on top
of the ankle
C. Apply the cold compress to the ankle
D. Consult with the HCP before applying the cold
compress Correct
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.
Test-Taking Strategy: Eliminate the comparable or alike options that involve
applying cold. To select from the remaining options, eliminate the option that
involves the application of heat, because the nurse would not apply heat to an
injury without a prescription to do so.
Review: the principles of heat and cold applications
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision-Making-Clinical Judgment-Critical Thinking,
Perfusion
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M.
(2013). Fundamentals of nursing. (8th ed., p. 1212). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
5. 5.ID: 22266441974A 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 Correct
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.
Test-Taking Strategy: Eliminate the comparable or alike options that are
effects of heat application. Also, recall the effects of heat and cold on the blood
vessels; this will help you eliminate the option that states that cold packs dilate
the blood vessels.
Review: the effects of heat and cold application
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Perfusion, Pain
HESI Concepts: Perfusion, Pain
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills
& techniques (8th ed., p. 986-987). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
6. 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?
A. Glomerulus
B. Urethra
C. Nephron
D. Ureterovesical junction Correct
Rationale: The ureterovesical junction is the point where the ureters enter the
bladder. At this junction, the ureter runs obliquely for 1.5 to 2 cm through the
bladder wall before opening into the bladder. This pathway prevents the reflux
of urine back into the ureter, in essence acting as a valve to prevent urine from
traveling back into the ureter and up to the kidney. The urethra extends from
the bladder to the opening of the body where urine is excreted. The nephrons
and glomeruli are located in the kidneys.
Test-Taking Strategy: Note the strategic words, most closely. Note that theclient has a bladder infection and focus on the subject, extension of the
infection to the kidneys. Visualizing the anatomy of the renal system will direct
you to the correct option.
Review: the anatomy of the kidney
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Elimination
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L.
(2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 1049). St. Louis: Mosby.
Awarded 100.0 points out of 100.0 possible points.
7. 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?
A. The client reports less thirst as compared with yesterday
B. The client reports socks which seem less tight on the ankle
area
C. The client’s weight remains stable, over the past two to three
days
D. 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: PharmacologyGiddens Concepts: Elimination,Fluids and Electrolytes
HESI Concepts: Elimination, Fluid & Electrolyte
Awarded 100.0 points out of 100.0 possible points.
8. 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.
9. 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. ApplesE. 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.
10. 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 [Show Less]