A client is being discharged home after a routine hip replacement surgery. The
nurse is instructing the client on how to prevent postoperative complications.
What statements by the client would indicate the need for fu
...
A client is being discharged home after a routine hip replacement surgery. The
nurse 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 Correct
D. Chronic illness Correct
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). Maternalchild 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
__________ = __________ = 0.5 tablets
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
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