The nurse is caring for a woman who is starting medroxyprogesterone injections
for birth control. What statements by the client would indicate a need for
further teaching? Select all that apply.
A. “I may experience s
...
The nurse is caring for a woman who is starting medroxyprogesterone injections
for birth control. What statements by the client would indicate a need for
further teaching? Select all that apply.
A. “I may experience some weight gain.” Incorrect
B. “I may not have regular periods while taking this medication.”
C. “I should return in approximately 6 months for my next injection.”
Correct
D. “Because it is highly effective, I can use this medication for many
years.” Correct
E. “Depression is a side effect, and I should let my doctor know if I
experience any mood changes.” Incorrect
Rationale: Medroxyprogesterone is an injectable progestin given every 3
months to prevent ovulation and pregnancy. It suppresses ovulation for 15
weeks, and therefore, timing of the next injection is very important and should
be no longer than exactly 3 months. Although medroxyprogesterone is highly
effective, it should not be taken for more than 2 years due to the risk of
osteoporosis. Weight gain, irregular periods, and depression are all known side
effects.
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. Specific knowledge about this medication is needed
to answer correctly. Remember that it needs to be given every 3 months and
should not be taken for more than 2 years due to the risk of osteoporosis.
Review: medroxyprogesterone injections
Level of Cognitive Ability:
Evaluating
Client Need:
Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area:
Pharmacology: Reproductive Medications
Priority Concepts: Client Education, Reproduction
HESI Concepts:
Sexuality/Reproduction, Teaching and Learning/Patient Education
Reference: Rosenjack Burchum, Rosenthal (2016), pp. 760-761.
Awarded -1.0 points out of 2.0 possible points.
2.ID: 9476801218
Following thyroid surgery, the nurse notes this response (refer to figure) when
taking the client’s blood pressure. On further assessment, which laboratory
finding would the nurse expect to find?
A. Serum calcium of 8.4 mg/dL (2.1 mmol/L)
B. Correct
C. Sodium level of 138 mEq/L (138 mmol/L)
D. Serum potassium of 5.1 mEq/L (5.1 mmol/L)
E.
F. Thyroid Stimulating Hormone (TSH) of 1.5 mU/L Incorrect
Rationale: Hypocalcemia is characterized by tetany, or sustained muscle
contractions. Chvostek’s sign is facial contractions seen after a light tap of the
facial nerve in front of the ear. Trousseau’s sign is carpal contraction when a
blood pressure cuff is inflated. These two signs are observed in hypocalcemia.
Test-Taking Strategy: Focus on the subject, thyroid surgery and the signs of
hypocalcemia. Use knowledge of signs of muscle contractions and its
association with a low calcium level. Note that hypocalcemia is a known
complication after thyroid surgery and serum calcium levels should be closely
monitored. Review: hypocalcemia.
Level of Cognitive Ability:
Synthesizing
Client Need:
Physiological Integrity
Integrated Process: Nursing Process/Analyzing
Content Area:
Fundamentals of Care: Fluids & Electrolytes
Priority Concepts: Cellular Regulation, Fluid and Electrolytes
HESI Concepts:
Cellular Regulation, Fluids and Electrolytes
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 298-299). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
3.ID: 9476805570
The charge nurse on a women’s health unit is making a client room assignment.
Which clients would be least appropriate to assign to share a room with a
woman who is pregnant? Select all that apply.
A. A client with hepatitis B Correct
B. A client with herpes zoster Correct
C. A client with pyelonephritis Incorrect
D. A client with hashimotos thyroiditis Incorrect
E. A client with a urinary tract infection
Rationale: Viral infections such as hepatitis B and herpes zoster can be very
serious for the mother and fetus if exposed and clients with these conditions
should not share a room with a pregnant client. Pyelonephritis, hashimotos
thyroiditis, and urinary tract infections can all have adverse effects on a
pregnant woman, however, these are not contagious conditions, and therefore
clients with these conditions can safely room share with a pregnant woman.
Test taking strategy: Focus on the strategic words least appropriate and select
the clients that should not share a room with a pregnant female. Think about the
infectious factors of each disorder in the options to answer correctly. Review:
risks of pregnancy
Level of Cognitive Ability:
Creating
Client Need:
Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area:
Maternity: Antepartum
Priority Concepts: Care Coordination, Infection
HESI Concepts: Care Coordination, Infection
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J.
(2013). Maternal-child nursing (4th ed., pp. 626-628). St. Louis: Elsevier.
Awarded -1.0 points out of 2.0 possible points.
4.ID: 9476805554
The home health nurse is caring for an older client recovering from pneumonia.
A concerned family member believes that the client is no longer capable of
caring for self effectively. The nurse conducts an assessment of the client’s
basic activities of daily living (BADLs). What activities would the nurse assess?
Select all that apply.
A. Eating Correct
B. Bathing Correct
C. Cooking Incorrect
D. Dressing Correct
E. Taking medications Incorrect
F. Balancing a checkbook
Rationale: ADL’s are basic activities that assess functional ability. Daily
activities such as eating, bathing, and dressing are considered basic every day
needs. Activities such as cooking, taking medication, and balancing a
checkbook are considered more complex, instrumental activities.
Test-taking Strategy: Focus on the subject, basic activities of daily living.
Select the answers that require the most basic care for completion. In addition,
specific knowledge of those activities that are basic and those that are
instrumental will assist in answering correctly. Review: Activities of Daily Living.
Level of Cognitive Ability:
Applying
Client Need:
Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Fundamental Skills: Safety
Priority Concepts: Functional Ability, Safety
HESI Concepts:
Functional Ability, Safety
References: Giddens, J. (2013). Concepts for nursing practice. (p. 12). St.
Louis, MO: Mosby.
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of
nursing. (8th ed., pp. 259-260). St. Louis: Mosby.
Awarded 1.0 points out of 3.0 possible points.
5.ID: 9476807948
The nurse is caring for a client who has recently undergone a right-sided
mastectomy for stage 3 breast cancer. When giving report to the next shift, what
information would be essential to communicate to the oncoming nurse? Select
all that apply.
A. Elevate the right arm on a pillow. Correct
B. Monitor skin color and for the presence of edema. Correct
C. Educate that a medical alert bracelet is being worn. Correct
D. Ensure the client refrains from any physical activity. Incorrect
E. Take blood pressure measurements on the right side only. Incorrect
Rationale: After a mastectomy, the nurse must assess for peripheral tissue
perfusion. Therefore it is important to assess skin color and for the presence of
edema. Elevation of the extremity will decrease venous pressure and decrease
edema. A medical alert bracelet should be worn at all times. A medical alert
bracelet should be worn to alert others and prevent anyone from using the
affected extremity for blood pressure, intravenous (IV punctures), or blood
draws because this could increase the likelihood of infection or decreased
tissue perfusion. Although the client should avoid heavy lifting, activity should be
encouraged and the client should participate in physical therapy unless
contraindicated.
Test-Taking Strategy: Note the strategic word essential when considering
what information should be included in shift change report. Think about what
information would be necessary for safe care of the client to help select the
correct answer. Also noting the words, any and only in options 4 and 5 will
assist in eliminating these options. Review: mastectomy
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Adult Health: Oncology
Priority Concepts: Care Coordination, Tissue Integrity
HESI Concepts:
Care Coordination, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., p. 1254-1255). St. Louis: Mosby.
Awarded -1.0 points out of 3.0 possible points.
6.ID: 9476793886
A client informs the nurse that she has recently started taking the herbal supplement
black cohosh for her menopausal symptoms. When reviewing the client’s medical
record, what finding would warrant the need for follow-up? Refer to chart.
H
i
s
t
o
r
y
a
n
d
P
h
y
s
i
c
a
l
Laboratory
Results
M
e
di
c
at
io
n
s
R
e
n
a
l
I
n
Thyroid
Stimulating
Hormone (TSH)
2.45 mIU/L
Gl
ipi
zi
de
5
m
g
s
u
f
f
i
c
i
e
n
c
y
or
al
on
ce
da
ily
H
e
a
r
t
f
a
i
l
u
r
e
B-type
natriuretic
peptide (BNP)
204 pg/ml
Si
m
va
st
at
in
4
0
m
g
on
ce
da
ily
A. TSH result
B. BNP result
C. Heart failure
D. Glipizide prescription Correct
Rationale:
Black cohosh is an herbal product used to treat hot flashes, irritability, and
palpitations. It potentiates insulin, oral hypoglycemic agents, and antihypertensive agents. Therefore, follow-up would be necessary if the client was
taking glipizide, a sulfonlyrea oral hypoglycemic agent. The TSH result is a
normal finding. The BNP result would be expected with a known diagnosis of
heart failure and additionally would not be affected by black cohosh.
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