Professional Documents
Culture Documents
D
D
1. Questions
1. 1.ID: 9477003586
The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate
to the nurse that the client understands what has been taught? Select all that apply.
A. Carrots
B. Tapioca Incorrect
C. Scallops Correct
D. Broccoli
A. Custard
A. Prunes Incorrect
B. Apples Correct
C. Peaches Correct
D. Avocados Incorrect
E. Nectarines
F. Cranberries Correct
Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally
high in potassium include dried prunes, avocado, bananas, fresh oranges and mangoes, nectarines, and papayas.
Test-Taking Strategy: Focus on the subject, fruits that are acceptable to eat.To answer this question correctly, you need to recall
that triamterene is a potassium-retaining diuretic, then identify the low-potassium foods. This will direct you to the correct options.
Review: triamterene and food items high and low in potassium.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Client Education, Fluids and Electrolytes
HESI Concepts: Teaching and Learning/Patient Education, Fluids and Electrolytes
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 1233-1235) St. Louis: Saunders.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 138). St. Louis: Mosby.
Awarded -1.0 points out of 3.0 possible points.
5. 5.ID: 9477000383
Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell
the client to maintain which type of diet, during the asymptomatic period?
A. Low in fat
D. High in carbohydrates
Rationale: When a client’s diverticulitis is asymptomatic, a soft high-fiber diet containing fruits, vegetables, and whole grains is
recommended. The client is also instructed to consume a small amount of bran daily and to take bulk-forming laxatives, if
prescribed, to increase stool mass and softness. Increasing fluid intake to 2500 to 3000 mL daily (unless contraindicated) is also
important. A low-fat diet may be healthy but is not specific to this disorder. A high-carbohydrate diet is not helpful for the client
with this condition.
Test-Taking Strategy: Focus on the subject, the “asymptomatic period.” Recalling the pathophysiology of this disorder and the
effects of the diets identified in the options will assist you in answering correctly. Review: dietary treatment for diverticulitis
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 995). St. Louis: Mosby.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 9477011688
A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to
eat? Select all that apply.
A. Avocados Incorrect
B. Baked tuna Correct
F. Cream cheese
Rationale: Fruits and vegetables tend to be lower in fat because they do not come from animal sources, although olives, though
technically a fruit, are high in fat (as are avocados), and fish is also naturally lower in fat. Meats and dairy products (e.g., cream
cheese) are higher in fat, although modifications can be made to these foods to reduce their fat content.
Test-Taking Strategy: Focus on the subject, low-fat foods. Recalling that dairy products are high in fat will eliminate cream cheese.
Remembering that some fruits and vegetables are high in fat will help you eliminate green olives and avocados. Review: foods high
and low in fat
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., pp. 715-716). St. Louis: Mosby.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby.
Awarded -1.0 points out of 3.0 possible points.
7. 7.ID: 9477003558
A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does
the nurse tell the client are acceptable to eat? Select all that apply.
A. Lettuce Incorrect
B. Cherries Correct
C. Broccoli Incorrect
D. Cabbage Incorrect
E. Potatoes Correct
F. Spaghetti Correct
Rationale: Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is
taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy
vegetables such as lettuce, broccoli, spinach, Brussels sprouts, cabbage, and turnip greens. Cherries, potatoes, and spaghetti are
foods that are low in vitamin K.
Test-Taking Strategy: Focus on the subject, dietary measures for the client on warfarin sodium. Recall that when a client is taking an
anticoagulant, foods high in vitamin K are often omitted from the diet. Knowledge regarding these food items will direct you to the
correct options. Review: foods high and low in vitamin K
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Client Education, Health Promotion
HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education
References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 105). St. Louis: Mosby.
Rosenjack Burchum, Rosenthal (2016) pp. 607, 622-623
Awarded -2.0 points out of 3.0 possible points.
8. 8.ID: 9477012954
A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will
promote wound healing does the nurse encourage the client to select from the hospital menu?
A. Peas Correct
B. Scrambled eggs
C. Cheese casserole
D. Mashed potatoes
Rationale: In general, flavorful, warm, or well-chilled foods with texture stimulate the swallow reflex. Moist pastas, casseroles, egg
dishes, and potatoes are usually well tolerated. Raw vegetables, chunky vegetables such as diced beets, stringy vegetables, and
those with skin, such as corn and peas are foods commonly excluded from the diet of a client with dysphagia.
Test-Taking Strategy: Focus on the subject, that the client has dysphagia. Select the food that would be most difficult to swallow;
this is the correct option. Review dietary measures for a client with dysphagia.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Neurological
Giddens Concepts: Intracranial Regulation, Safety
HESI Concepts: Intracranial Regulation, Safety
References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 354-355). St. Louis: Mosby.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 769-770). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
10. 10.ID: 9477007710
A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the
therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance?
A. Fats Incorrect
B. Vitamins
C. Potassium Correct
D. Carbohydrates
Rationale: Most excretion of potassium and control of potassium balance is carried out by the kidneys. In the client with AKI,
potassium intake is limited. The primary mechanism of potassium removal during AKI is dialysis. Vitamins, carbohydrates, and fats
are not normally restricted in the client with AKI.
Test-Taking Strategy: Note the diagnosis and focus on the subject, dietary measures for the client with AKI. Recalling the normal
functions of the kidneys will direct you to the correct option. Review the therapeutic diet for the client with acute kidney injury
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Client Education, Fluid and Electrolytes
HESI Concepts: Teaching and Learning/Patient Education, Fluid and Electrolytes
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 1106). St. Louis: Mosby.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 431-432). St. Louis:
Mosby.
Awarded 0.0 points out of 1.0 possible points.
11. 11.ID: 9477002355
A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize
the risk of complications? Select all that apply.
A. Left heel
B. Scapulae Incorrect
A. Toast
B. Plain bagel
D. Scrambled eggs
Rationale: A full liquid diet consists of liquid foods that are clear or opaque liquid foods, including those that are liquid at room
temperature. Cooked custard is allowed on a full liquid diet. Toast and a bagel are allowed on a regular diet (a diet with no
restrictions). Scrambled eggs are allowed on a soft diet.
Test-Taking Strategy: Focus on the subject, foods allowed on a full liquid diet. Remembering that a full liquid diet consists of liquid
foods that are clear or opaque, including those that are liquid at room temperature will direct you to the correct option. Review the
foods allowed on a full liquid diet
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Nutrition
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Health, Wellness, and Illness
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
15. 15.ID: 9477005736
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. Peas Correct
B. Broccoli Correct
C. Potatoes Correct
D. Red wine
E. Avocados Incorrect
A. Alcohol Correct
B. Diet cola
C. Bran flakes
D. Chicken livers
Rationale: A disulfiram-type reaction may result when someone taking metronidazole ingests alcohol. This syndrome includes
flushing, palpitations, shortness of breath, severe headache, and nausea. To help prevent this reaction, the nurse must warn the
client not to drink alcohol while taking this medication. The items presented in the remaining options are acceptable for
consumption by the client while taking this medication.
Test-Taking Strategy: Focus on the subject, substances to eliminate from the diet when a client is taking metronidazole. Use general
medication guidelines to answer correctly and recall that alcohol can affect the action of many medications. This will assist in
directing you to the correct option. Review metronidazole and the associated dietary regimen
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Client Education, Safety
HESI Concepts: Teaching and Learning/Patient Education, Safety
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 1196-1197
Awarded 1.0 points out of 1.0 possible points.
18. 18.ID: 9477010198
Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium
absorption, instruct the client to limit in the diet? Select all that apply.
A. Bran Correct
B. Milk
C. Clams Incorrect
D. Spinach Correct
A. Prunes
B. Oranges
C. Rhubarb Correct
D. Cranberries
Rationale: When a client is taking nitrofurantoin, the urinary pH must be maintained in the acid range, and so the client needs to be
instructed to consume an acid ash diet. Rhubarb reduces the acidity of the urine and should be avoided when acidic urine is
required. Prunes, oranges, and cranberries are acceptable foods.
Test-Taking Strategy: Focus on the subject, the food to eliminate when taking nitrofurantoin. Recall that the urinary pH must be
maintained in an acid range. Next, recalling the items that are acid ash foods will direct you to the correct option. Review
nitrofurantoin and acid ash foods
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. 856-857) St. Louis: Saunders.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 443). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
21. 21.ID: 9477011664
For which vitamin deficiency should the nurse monitor the client who is on a vegan diet?
A. Vitamin A
C. Vitamin C
D. Vitamin E
Rationale: The client on a vegan diet does not consume animal products and is therefore at risk for vitamin B 12 deficiency. Fruits and
vegetables, which are acceptable to the client on a vegan diet, contain vitamins A, C, and E.
Test-Taking Strategy: Focus on the subject, a vegan diet. Recalling that vitamin B12 is found in animal products will direct you to the
correct option. Review the components of a vegan diet
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Nutrition
Giddens Concepts: Health Promotion, Nutrition
HESI Concepts: Health, Wellness, Illness; Metabolism – Nutrition
Reference: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 54). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
22. 22.ID: 9477006357
A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client?
A. Milk
B. Cabbage Incorrect
A. Eggs
B. Yogurt Correct
C. Parsley Correct
D. Broccoli
E. Cucumbers Incorrect
B. Pasta
C. Boiled rice
A. Beef Correct
B. Custard
C. Potatoes
D. Cantaloupe Incorrect
Rationale: Chemotherapy may distort how certain foods taste to the client. Beef and pork are often reported by people undergoing
chemotherapy to taste bitter or metallic. The nurse can promote nutrition by helping the client choose alternative sources of
protein. The foods set forth in other options are not likely to cause this problem.
Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, foods that may taste unpleasant to the client
undergoing chemotherapy.Remember that some meat products are subject to this problem. Review the foods that cause
unfavorable tastes for the client undergoing chemotherapy
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Oncology
Giddens Concepts: Cellular Regulation, Nutrition
HESI Concepts: Cellular Regulation, Metabolism-Nutrition
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 266). St. Louis: Mosby.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 481). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
28. 28.ID: 9476999146
A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz (240 ml) of
nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which
action will be taken after eating the nonfat yogurt?
A. Milk
B. Peanuts Correct
C. Chicken
D. Broccoli Incorrect
E. Asparagus Correct
D. “My risk for malnourishment is much higher while I’m pregnant.” Correct
Rationale: Although pregnancy poses some nutritional risk for the mother, the client is not at risk of becoming malnourished.
Calcium intake is critical during the third trimester, but calcium intake must be increased from the start of pregnancy. Adequate
nutrition during pregnancy significantly and positively influences fetal growth and development. Intake of dietary iron and vitamins
is insufficient for the majority of pregnant women, and the use of iron and vitamin supplements is routinely encouraged.
Test-Taking Strategy: Note the strategic words “need for further instruction,” which indicate a negative event query and the need to
select the incorrect statement. Recall the principles of good nutrition during pregnancy to answer the question. Also, note the
words “My risk for malnourishment” in the correct option.Review the components of nutrition during pregnancy.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Client Education, Nutrition
HESI Concepts: Health, Wellness, and Illness – Health Promotion, Teaching and Learning/Patient Education
Reference: Lowdermilk et al (2016) pp. 317, 345-346
Awarded 1.0 points out of 1.0 possible points.
32. 32.ID: 9477002314
A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the
nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for that may be causing this
problem?
A. Maltose
B. Lactose Correct
C. Sucrose
D. Fructose
Rationale: Several tube-feeding formulas contain lactose. A client with a history of lactose intolerance would experience the
symptoms identified in the question if one of these formulas were administered. If the client is found to be lactose intolerant, the
health care provider should prescribe a lactose-free formula. This will resolve the client’s symptoms and promote adequate
nutrition for the client.
Test-Taking Strategy: Focus on the data in the question and note the word “ingredient” in the query of the question. Answering the
question correctly depends on the ability to associate the symptoms of lactose intolerance with the client’s situation. This
association will direct you to the correct option. Review the symptoms of lactose intolerance
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Nutrition
Giddens Concepts: Elimination, Nutrition
HESI Concepts: Elimination, Metabolism- Nutrition
References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 899). St. Louis: Mosby.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 459). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
33. 33.ID: 9477003528
A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the
client? Select all that apply.
A. Lentils Correct
B. Raisins Correct
C. Pineapple
D. Egg whites
A. Fish
B. Spinach
C. Rhubarb
A. Pork
B. Beef
C. Eggs Correct
D. Raisins Incorrect
Rationale: One large egg provides 66 mg of potassium. A half-cup (114 gm) of raisins contains 700 mg of potassium. Four ounces
(113 gm) of beef contains 420 mg of potassium, and 4 oz of pork (113 gm) contains 525 mg.
Test-Taking Strategy: Note the strategic words “needs further instruction,” which indicate a negative event query and the need to
select the incorrect option. Use your knowledge regarding the potassium content of various foods. Remember, most meats and
dried fruits are high in potassium. Review the foods that are high and low in potassium
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Metabolism-Nutrition
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 183). St.
Louis: Saunders.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 138). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
36. 36.ID: 9477000319
A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to
include more of in the daily diet?
C. Give the client a back massage and prepare the client for sleep
D. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and
straightening the bed linens Correct
Rationale: Afternoon hygiene care includes washing the client’s hands and face and performing mouth care, offering a bedpan or
urinal, and straightening the bed linens. It does not involve giving a complete bed bath. Giving the client a back massage and
preparing the client for sleep are components of evening or hour-before-sleep care. Asking the client whether he would like to wash
his face encourages independence but is not one of the components of afternoon care.
Test-Taking Strategy: Focus on the subject, afternoon care. This will assist you in eliminating the options of giving the client a
complete bed bath and giving the client a back massage and preparing the client for sleep. To select from the remaining options,
eliminate asking the client whether he would like to wash his face, because it demonstrates an incomplete performance of
afternoon care. Review hygiene measures for the client
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership and Management
Giddens Concepts: Caregiving, Safety
HESI Concepts: Caregiving, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 392-394). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
40. 40.ID: 9477000343
A client requires a partial bed bath. The nurse, giving instructions to an unlicensed assistive personnel (UAP) about the bath, tells
the UAP to take which action?
A. Just wash the client’s hands and face
D. Bathe the client’s body parts that, if left unbathed, would give rise to discomfort or odor Correct
Rationale: A partial bed bath involves bathing the body parts that would give rise to discomfort or odor if they were left unbathed.
This includes the axillary and perineal areas and any skin folds. The incorrect options do not completely reflect a partial bed bath.
Test-Taking Strategy: Focus on the subject, a partial bed bath. Eliminate the option that includes the closed-ended word “just” and
the option that includes the word “only.” To select from the remaining options, recall the definition of a partial bed bath; this will
direct you to the correct option. Review the components of a partial bed bath
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Leadership and Management
Giddens Concepts: Caregiving, Safety
HESI Concepts: Caregiving, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 395). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
41. 41.ID: 9476998580
An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The
nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which
action?
C. Turning up the thermostat in the client’s room for the bath Incorrect
D. Keeping the side rails (per agency policy)up while away from the client
Rationale: A complete bed bath is for clients who are totally dependent and require total hygiene care. The nurse would promote
independence and encourage the client to assist as much as possible in the bath. The nurse would maintain the room’s warmth
because the client is partially uncovered and may easily be chilled. Privacy is always maintained, and the nurse maintains safety by
keeping the side rails up (per agency policy) while away from the client’s bedside.
Test-Taking Strategy: Note the strategic words “needs instruction” which indicate a negative event query and the need to select the
incorrect action by the UAP. Recalling that it is important to encourage independence will direct you to the correct option. Review
the guidelines for bathing a client
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Leadership and Management
Giddens Concepts: Caregiving, Safety
HESI Concepts: Caregiving, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 395). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
42. 42.ID: 9477010170
A nurse notes documentation in a client’s medical record indicating that the client is experiencing oliguria. On the basis of this
notation, the nurse determines which about the client when planning care?
B. That her child is too young and that she should not yet be worrying about it
C. That a child cannot begin to control urination until approximately the age of 24 months Correct
D. That bowel training should be started immediately and then begin bladder training in about 1 month
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 1.0 points out of 1.0 possible points.
44. 44.ID: 9477008796
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. Urethra
B. Nephron
C. Glomerulus Incorrect
A. Physiological stress
C. Release of norepinephrine
A. 100 mL
B. 250 mL
C. 400 mL Correct
D. 800 mL Incorrect
Rationale: With approximately 400 mL of urine in the bladder, the client will feel a sensation of bladder fullness. This amount may
be altered by habit and may differ slightly from person to person, but the other options are nonetheless incorrect.
Test-Taking Strategy: To answer this question correctly, you must be familiar with the anatomy of the bladder and its urine-holding
capacity. Focusing on the subject, a sensation of fullness in the bladder, will assist you in eliminating the lowest amounts of urine
(100 and 250 mL). To select from the remaining options, focus on the subject and think about the capacity of the bladder. Review
the anatomy and physiology of the bladder
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Elimination
Giddens Concepts: Development, Elimination
HESI Concepts: Developmental, Elimination
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 1050). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
48. 48.ID: 9477002368
A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that
the kidneys will respond to this via which physiological action?
C. Collecting duct
D. Proximal tubule
Rationale: Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle.
Furosemide does not exert an effect on the areas identified in the other options.
Test-Taking Strategy: Focus on the subject, the effect of furosemide on the kidney. Specific knowledge of the site of action of this
medication is needed to answer this question. Recalling that furosemide is a loop diuretic will assist in directing you to the correct
option. Review furosemide.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Pharmacology
Giddens Concepts: Cellular Regulation, Elimination
HESI Concepts: Cellular Regulation, Elimination
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015.
(p. 530) St. Louis: Saunders.
Awarded 0.0 points out of 1.0 possible points.
50. 50.ID: 9477007797
A client complains of feeling fatigued because of the need to get up several times during the night to urinate. The nurse documents
that the client is experiencing which problem?
A. Anuria
B. Oliguria
C. Polyuria
D. Nocturia Correct
Rationale: Nocturia is excessive urination at night. Anuria is the inability to produce urine. Oliguria is a diminished capacity to form
urine. Polyuria is excessive urine output.
Test-Taking Strategy: Focus on the subject, frequent urination at night. Use medical terminology and note the relationship between
the subject, urination during the night, and the correct option. Review nocturia
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Elimination
Giddens Concepts: Elimination, Sleep
HESI Concepts: Elimination, Comfort
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 1054, 1056). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
51. 51.ID: 9477007788
A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective
data from the client, should most appropriately ask the client about which?
A. Plums Correct
B. Prunes Correct
C. Apples Incorrect
D. Broccoli
E. Cabbage
F. Cranberries 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: Client Education, Health Promotion
HESI Concepts: Teaching and Learning/Patient Education, Health, Wellness, and Illness
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 2.0 points out of 3.0 possible points.
54. 54.ID: 9477011654
A nurse is caring for a client who has just returned from a cardiac catheterization through the right side of the groin. The client tells
the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action
should the nurse take to stimulate the client’s micturition reflex?
C. Turning on the water in the sink in the client’s room and allowing it to run Correct
D. Obtaining assistance to ambulate the client to the bathroom in the client’s room
Rationale: To stimulate the micturition reflex, the nurse may provide sensory stimuli such as placing the client’s hand in a pan of
warm water, warming a bedpan if one is needed for use, running water from a faucet and encouraging the client to listen to it,
pouring water over the client’s perineum, and encouraging fluid intake. The incorrect options are all inappropriate because the
client who has just returned from a cardiac catheterization should remain in bed and head elevation should be minimal to prevent
the formation of a hematoma at the catheter insertion site.
Test-Taking Strategy:Eliminate the options that are comparable or alike first because they both indicate that the client may get out
of bed. To select from the remaining options, note that the client has undergone cardiac catheterization, which will direct you to
the correct option. Review measures to stimulate micturition
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Elimination
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 1059). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
55. 55.ID: 9477012984
A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac
disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client
consume each day?
A. 500 to 1000 mL
B. 1000 to 1500 mL
B. That she should cleanse the perineum from front to back Correct
C. That she should collect the urine in the cup as soon as the urine flow begins
D. That she should collect the specimen at bedtime and bring it to the laboratory the next morning
Rationale: As part of correct procedure, the client should cleanse the perineum from front to back, using the antiseptic swabs
packaged with the specimen kit. The client should begin the flow of urine, then collect the sample. The specimen should be sent to
the laboratory as soon as possible. It should not be allowed to stand, because improper specimen handling could yield inaccurate
test results. It is not normal procedure to douche before collecting the specimen.
Test-Taking Strategy: Focus on the subject, a midstream urine specimen. Noting the type of sample, midstream, will assist you in
eliminating the option of collecting the urine in the cup as soon as urine flow begins. The knowledge that the specimen should be
brought to the laboratory as soon as possible after collection will assist you in eliminating the option of collecting the specimen at
bedtime and bringing it to the laboratory the next morning. Use your knowledge of the basic principles of hygiene to select the
correct option from the two that remain. Review the procedure for collecting a midstream urine sample.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Infection Control
Giddens Concepts: Client Education, Infection
HESI Concepts: Teaching and Learning/Patient Education, Infection
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 1057). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
57. 57.ID: 9477006395
A nurse is monitoring a client’s fluid balance. Which 24-hour intake and output totals indicates to the nurse that the client has the
proper fluid balance?
C. The client moves the cane and the unaffected side together Correct
D. The client uses the cane to support the affected side and to maintain balance Incorrect
Rationale: The client should move the cane and the affected side together. The cane helps support the affected side as it moves
forward. It also helps the client maintain balance. The client holds the cane close to the body to keep from leaning. The client holds
the cane on the unaffected side to shift the client’s weight away from the affected side. The cane’s handle should reach the level of
the greater trochanter of the client’s femur, with 25 to 30 degrees flexion at the client’s elbow.
Test-Taking Strategy: Note the strategic words “needs additional instruction,” which indicate a negative event query and the need
to select the incorrect action. Visualize each of the options to find the correct option. Review the procedure for the use of a cane.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 245-246). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
60. 60.ID: 9477012944
A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the
underside of the arm on the crutch pad, mainly because it could result in which problem?
A. Skin breakdown
C. An abnormal stance
Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed between 6
and 10 inches (15 to 25.5 cm) in front and to the side of the client, depending on the client’s body size, providing a wide enough base
of support and improving the client’s balance. The remaining options are incorrect.
Test-Taking Strategy: Focus on the subject, safe use of crutches. Two inches (5 cm) and 22 inches (56 cm) seem excessively short
and long, respectively, and are eliminated first. Visualize the descriptions in the remaining options. Eight inches (20 cm) seems
more in keeping with the normal length of a stride than 15 inches (38 cm).. Review the points related to client instructions for the
use of crutches.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 239-240). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
62. 62.ID: 9477003506
A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the
teaching plan? Select all that apply.
A. It is not safe to use someone else’s crutches. Correct
C. The client should use both crutches when navigating stairs. Correct
D. Lean into the crutches as needed to support the body’s weight. Incorrect
E. Crutch tips are made of a material that will not wear down.
Rationale: The client should use only crutches that have been measured and set for him. When ascending or descending stairs, the
client generally uses a three-phase sequence involving both crutches. Crutch tips should be kept as dry as possible. Water could
cause slippage by reducing the friction of the rubber tip against the floor. If the tips get wet, the client should dry them with a cloth
or paper towel. The tips should be inspected for wear, and spare crutches and tips should be available. Leaning into the crutches to
support the body’s weight increases the risk of axillary nerve injury.
Test-Taking Strategy: Focus on the subject, instructions regarding the use of crutches. Noting that the correct options are related to
safety should direct you to them. Review client teaching points for the safe use of crutches
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 761). St. Louis: Mosby.
Awarded 1.0 points out of 2.0 possible points.
63. 63.ID: 9477011646
A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which
way?
C. Leans on the cane when the right leg moves forward Incorrect
D. Keeps the cane 6 inches (15 cm) out to the side of the right
Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support.
The cane is held 6 inches (15 cm) lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on
the cane for added support while the stronger side moves forward.
Test-Taking Strategy: Note the strategic words “needs further teaching,” which indicate a negative event query and the need to
select the incorrect action. First recall that the cane is held on the stronger side. Next recall that the client moves the cane with the
weaker leg and leans on it for support when the stronger leg moves forward. Review client instructions for use of a cane
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Safety
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 240, 245-246). St. Louis:
Mosby.
Awarded 0.0 points out of 1.0 possible points.
65. 65.ID: 9477000307
A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should
use which for repositioning?
A. Pillow to keep the right leg abducted while turning the client Correct
C. Trochanter roll to keep the right leg adducted while turning the client
D. Rolled bath blanket to prevent external rotation while turning the client
Rationale: After internal fixation of a hip fracture, the client is turned to the affected side or the unaffected side as prescribed by the
surgeon. Before moving the client, the nurse places a pillow between the client’s legs to keep the affected leg in abduction. The
client is then repositioned and proper alignment and abduction are maintained. A trochanter roll or rolled bath blanket is useful in
preventing external rotation, but it is used once the client has been repositioned. It is not used while the client is being turned.
Test-Taking Strategy: Focus on the subject, the procedure for repositioning the client. Visualizing each description in the options
and recalling that the affected leg remains abducted will direct you to the correct option. Review care of the client who has
undergone hip surgery
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 1526). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
66. 66.ID: 9476999100
A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement.
Which action should the nurse take to protect the knee?
A. Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg Incorrect
B. Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is
sitting
C. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place.
D. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is
sitting Correct
Rationale: The nurse helps the client get out of bed after putting a knee immobilizer on the affected joint for stability. A
compression dressing (a.k.a. elastic wrap or Ace bandage) is usually applied after the surgical procedure is complete. The surgeon
prescribes weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in a chair to minimize edema. A
CPM machine may be prescribed by some surgeons and is used while the client is in bed.
Test-Taking Strategy: Focus on the information in the question noting that it is the first postoperative day. A compression dressing
should already be in place on the wound, so covering the surgical dressing with an elastic wrap is eliminated. Because the CPM
machine if prescribed is used while the client is in bed, lifting the client to the bedside chair, leaving the CPM machine in place, is
eliminated. To select from the remaining options, recall that ambulation is not started usually until the second postoperative day,
which will direct you to the correct option. Also, a knee immobilizer is most appropriate for protection of the knee joint. Review
care of the client after total knee replacement
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 329-330
). St. Louis: Saunders.
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 231-233). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
67. 67.ID: 9477010149
The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion
after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene?
Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 217-218). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
68. 68.ID: 9477010128
A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back
care. The nurse determines that the client needs further instruction if the client makes which statement?
D. “I should get out of bed by sitting up straight and swinging my legs over the side of the bed.” Correct
Rationale: Clients are taught to get out of bed by sliding near the edge of the mattress, then rolling onto one side and pushing up
from the bed, using one or both arms. The back is kept straight and the legs are swung over the side. Proper body mechanics
includes bending at the knees, not the waist, to lift objects. Increased fluids and fiber in the diet help prevent straining at stool and,
in turn, increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening the lower back muscles.
Test-Taking Strategy: Note the strategic words “needs further instruction,” which indicate a negative event query and the need to
select the incorrect action. Recall that the client with low back pain should avoid actions and movements that increase intraspinal
pressure. This will direct you to the correct option. Review client teaching regarding body mechanics
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Safety
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 197-198). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
69. 69.ID: 9476999170
A client has been placed in Buck’s extension traction. The nurse can provide counter traction to reduce shear and friction by
implementing which measure?
B. Removing the catheter and contacting the health care provider (HCP)
C. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon Correct
D. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon
Rationale: If the balloon is malpositioned in the urethra, inflating the balloon could produce trauma, resulting in pain. If pain occurs,
the fluid should be aspirated and the catheter inserted a little farther to provide sufficient space in which to inflate the balloon. The
catheter’s balloon is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is
inflated inside the bladder and not in the urethra. There is no need to remove the catheter or call the HCP. Because pain on balloon
inflation is not normal, having the client take deep breaths is not an appropriate action.
Test Taking Strategy: Focus on the information in the question noting the subject of the question, the client’s complaint of
discomfort. Visualize this procedure and the anatomy of the urinary system to answer this question. Review the procedure for
inserting a urinary catheter.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Renal and Urinary
Giddens Concepts: Elimination, Pain
HESI Concepts: Elimination, Comfort-Pain
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 819-820). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
71. 71.ID: 9477011674
A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to
flow into the tubing. At this point, the nurse should take which action?
C. Wait until the urine flow stops and inflate the balloon
D. Insert the catheter until resistance is met and inflate the balloon Incorrect
Rationale: The catheter’s balloon is behind the opening at the insertion tip. The catheter is inserted 2.5 to 5 cm after urine begins to
flow to provide sufficient space in which to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon
is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could inflict trauma.
Test-Taking Strategy: Focus on the subject, the procedure for bladder catheterization. Knowledge of the proper procedure for
inserting an indwelling urinary catheter will assist you in answering this question. First eliminate the option that includes the word
“immediately.” Next visualize this procedure, which will direct you to the correct option.Review the procedure for bladder
catheterization.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Adult Health/Renal and Urinary
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 815-816). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
72. 72.ID: 9477005746
A nurse is preparing to administer an enema to a client. In which position does the nurse place the client?
A.
B.
C. Correct
D.
Rationale: When an enema is administered, the client is placed in the left-lying Sims position so that the enema solution may flow
by way of gravity in the natural direction of the colon. Although the knee-chest position does provide exposure to the rectal area,
the position is uncomfortable and embarrassing for the client. The supine and the prone positions do not provide adequate
exposure or promote gravity flow in the natural direction of the colon.
Test-Taking Strategy: Focus on the subject, administering an enema and use your knowledge of the anatomy of the bowel to
answer the question. This will assist you in eliminating the prone position. Visualize the procedure for administering an enema and
eliminate the dorsal recumbent option. To select from the remaining options, determine which position would be most
comfortable for the client; this will direct you to the correct option. Review the procedure for administering an enema
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Elimination
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 853). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
73. 73.ID: 9477011611
A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with
which information?
B. The child will let you know when she is ready to begin bowel training Incorrect
C. Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than
boys do
D. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of
age Correct
Rationale: Infants and young children are unable to control defecation because of a lack of neuromuscular development. This
development usually does not take place until 2 to 3 years of age. A child’s letting the parent know when he or she is ready to begin
bowel training is not a sign of readiness. There is no difference between neuromuscular development in girls and that in boys.
Test-Taking Strategy: Focus on the subject of bowel training. Specific knowledge regarding patterns of growth and development is
needed to answer this question. Review concepts related to bowel elimination
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Developmental Stages
Giddens Concepts: Development, Elimination
HESI Concepts: Developmental, Elimination
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 137). St. Louis:
Elsevier.
Awarded 0.0 points out of 1.0 possible points.
74. 74.ID: 9477012928
A nurse is developing a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should
the nurse include in the plan of care to help maintain an appropriate bowel elimination pattern?
A. 250 mL
B. 500 mL
C. 750 mL Incorrect
D. 1000 mL Correct
Rationale: Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through the
infusion of a large volume of solution or local irritation of the colon’s mucosa. The maximal volume of solution for an adult is 1000
mL.
Test-Taking Strategy: Focus on the subject, the procedure for administering a cleansing enema. Remember that the maximal
volume of solution for an adult is 1000 mL. Review the procedure for administering an enema
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Elimination
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 852). St. Louis: Mosby.
Awarded 0.0 points out of 1.0 possible points.
77. 77.ID: 9477005705
A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal
matter, which the nurse interprets as a poor result. The nurse should take which action?
D. Allow the client to rest for 1 hour and then continue with another enema
Rationale: “Enemas until clear” means that the enema is repeated until the client passes fluid that is clear and contains no fecal
material. It may be necessary to give as many as three enemas. Excessive enema use seriously depletes fluids and electrolytes. If
the fluid fails to return clear after three enemas (check agency policy), the physician should be notified. Therefore the other options
are incorrect.
Test-Taking Strategy: Eliminate the incorrect options because they are comparable or alike and indicate that the enemas should be
repeated. Review the procedure for administering enemas until clear
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Elimination
Giddens Concepts: Clinical Judgment, Elimination
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 853). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
81. 81.ID: 9477002396
A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client,
the nurse begins the procedure. The nurse inserts the rectal tube into the client’s rectum a maximal distance of of how many
inches?
C. Stop the instillation and allow the client to expel the solution
B. “We should probably have the baby checked out by the doctor.”
C. “If you see any other neurological alterations, call the pediatrician.”
F. Get up at the same time each day and avoid naps during the day. Correct
Rationale: A variety of measures may be used to promote and enhance sleep. These measures include avoiding caffeinated
beverages (caffeine is a stimulant) for at least 2 hours before bedtime, avoiding alcohol, maintaining a regular exercise schedule but
not exercising immediately before bedtime, getting up at the same time each day, avoiding naps during the day, adjusting the
room temperature to a comfortable level, and eliminating lights, noise, and other environmental distractions. Alcohol can lighten
and fragment sleep. Exercising just before bedtime promotes stimulation and may prevent sleep. Black tea contains caffeine.
Test-Taking Strategy: Focus on the subject, measures to promote and enhance sleep. Think about each measure in terms of its
enhancing or preventing sleep to identify the correct measures. Review measures to promote sleep
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Rest and Sleep
Giddens Concepts: Client Education, Sleep
HESI Concepts: Teaching and Learning/Patient Education, Comfort
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
clinical problems (9thed., p. 103). St. Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
88. 88.ID: 9477008747
A client asks a nurse about complementary and alternative measures to promote sleep. What should the nurse suggest?
A. Herbal therapy
B. Acupuncture
A. Polyuria
B. Diarrhea
C. Tachycardia Correct
D. Hypotension Correct
D. Become less aware of pain by creating and then concentrating on a mental image Correct
Rationale: In guided imagery, the client creates a mental image and then concentrates on the image, becoming less aware of pain
and other stimuli. Hypnosis can help alter pain perception through the influence of positive suggestion. Certain distraction
techniques, such as music, can help a client ignore pain. No alternative or complementary therapy will allow the client to become
totally unaware of pain.
Test-Taking Strategy: Use Focus on the subject, guided imagery. First eliminate the option that contains the word “totally.” To
select from the remaining options, note the relationship between the words “guided imagery” in the question and the correct
option. Review the concepts of guided imagery
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Complementary and Alternative Therapies
Giddens Concepts: Coping, Pain
HESI Concepts: Stress and Coping, Pain
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 367). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
95. 95.ID: 9477000333
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?
B. Consult with the HCP before applying the cold compress Correct
C. Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes Incorrect
D. Elevate the ankle and place cold compresses under and on top of the ankle
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 options that are comparable or alike in that they 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, 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 0.0 points out of 1.0 possible points.
97. 97.ID: 9476999116
A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further
instructionif the client makes which statement?
A. The PCA pump eliminates the need for an intravenous (IV) line
B. The client will be able to deliver his own dose of medication every 4 hours
C. The client’s spouse will be able to administer medication for the client
D. The client administers his own medication by pressing a control button Correct
Rationale: A PCA pump contains a cartridge or syringe that holds the prescribed pain medication. The client pushes a button to
administer a small dose of medication within the limitations prescribed by the health care provider. The pump allows the delivery of
small doses of medication at short intervals. The medication is administered by way of the IV route. Only the client should
administer the medication as he or she needs it.
Test-Taking Strategy: Focus on the subject, the use of a PCA pump.. Focusing on the name of the pump — patient-controlled
analgesia — and recalling the principles of how the pump works will direct you to the correct option. Review a PCA pump as a pain
relief measure
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology
Giddens Concepts: Client Education, Pain
HESI Concepts: Teaching and Learning/Patient Education, Pain-Comfort
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 353-354). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
100. 100.ID: 9477010185
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply.