Saunders Review Test 1

Saunders Review Test 1
1.ID: 6
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, ). St. Louis: Mosby.
Awarded 3.0 points out of 3.0 possible points.
2.ID: 8
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: 4
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: 9
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: 3
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. ...............Continued................