HESI COMPASS - MODULE 7 Exam - Basic Care and Comfort

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 which information to the mother? A. That a child cannot begin to ...

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 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