NSG 201 Saunders Review Test1 Questions Answers
1.ID: 9477033456
A client is being discharged home after a routine hip replacement surgery. The nurse
... [Show More] 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, 1089-1090). St. Louis: Mosby. Awarded 3.0 points out of 3.0 possible points.
2.ID: 9477039828
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: 9477038294
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: 9477033419
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: 9477032613
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
D. Chronic illness
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: 9477043118
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). Maternal-
child nursing (4th
ed., pp. 1492-1493). St. Louis: Elsevier. Awarded -1.0 points out of 2.0 possible points.
7.ID: 9477035226
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
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: 9477039851
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
a t o r y
r a l e s o n
a u s c u l t a t i o n
sur e 14
5/
94
m m Hg
2
0
m g or all y da ily
P
e r i p h e r a l V
a
Se ru m Po tas siu m 3.
5
m Eq
/L
At or va st at in 1
0
m 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: 9477033433
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: 9477034772
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. 1325-1326. Awarded 1.0 points out of 3.0 possible points.
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