NUR MISC / Focus on Adult Health
. ID: 9477061444
. A nurse is monitoring a client who is taking spironolactone for the treatment of
hypertension. Which findings denote adverse effects of the medication? Select
all that apply.
A. Constipation
B. Tall T waves Correct
C. Hyporeflexia
D. Shallow respirations
E. Prolonged PR interval Correct
F. Hyperactive bowel sounds Correct
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
diuretics can cause hyperkalemia. Cardiovascular manifestations of
hyperkalemia include tall T waves, widened QRS complexes, prolonged PR
intervals, and flat P waves. Other cardiovascular manifestations include an
irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle
twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also
occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are
signs of hypokalemia.
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sparing diuretic will assist you in determining that hyperkalemia is an adverse
effect of the medication. Recalling the manifestations of hyperkalemia will direct
you to the correct options. Also, note that the incorrect options are comparable
or alike in that they indicate a slowed body response or function. Review the
adverse effects of spironolactone and the manifestations of hyperkalemia if you
had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Pharmacology
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and
Electrolytes
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook
2015. (pp. 1125-1127) St. Louis: Saunders.
. Awarded 3.0 points out of 3.0 possible points.
. 2.ID: 9477057138
, NUR MISC / Focus on Adult Health
. A nurse is providing dietary instructions to a client with chronic obstructive
pulmonary disease (COPD) who is experiencing a loss of appetite and
complains of feeling “too full to eat.” What does the nurse encourage the client
to do? Select all that apply.
A. Avoid drinking fluids before and during meals Correct
B. Eat a variety of dark-green vegetables, such as broccoli
C. Have snacks, such as crackers and cheese, between meals
D. Select foods that are easy to chew and are not gas forming Correct
E. Consume high-calorie drinks, such as milkshakes, between meals
. Rationale: COPD is a progressive and irreversible condition characterized by
diminished inspiratory and expiratory capacity of the lungs. Instruct the client
who complains of feeling too full to eat, to avoid drinking fluids before and
during the meal. Dry foods such as crackers stimulate coughing; foods such as
milk and chocolate may increase the thickness of saliva and secretions. Cheese
is constipating and should also be avoided by the client. The nurse should also
teach the client about foods that are easy to chew and do not encourage the
formation of gas; for this reason, broccoli, which is a gas-forming food, should
be avoided.
. Test-Taking Strategy: Use the process of elimination. Recalling that milk may
increase the thickness of saliva will assist you in eliminating the option that
encourages the consumption of milkshakes. Eliminate the option in which the
consumption of broccoli is encouraged, because it is a gas-forming food. To
select from the remaining options, note the strategic words “too full to eat” in the
question and the option that encourages the client to avoid fluids before and
during meals; this will direct you to the correct answers. Review dietary
measures for the client with COPD if you had difficulty with this question.
. Level of Cognitive Ability: Applying
. Client Needs: Physiological Integrity
. Integrated Process: Teaching and Learning
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Gas Exchange, Nutrition
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 595-596). St. Louis: Mosby.
. Awarded 2.0 points out of 2.0 possible points.
. 3.ID: 9477057160
. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
,NUR MISC / Focus on Adult Health
infection. Forty-eight hours after administration, the nurse checks the test site
(see image).
.
. The nurse documents the result of the test as:
A. Positive Correct
B. Negative
C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis
(TB) infection. A reaction measuring 5 mm or more in diameter is considered
positive in a client with HIV infection. A reaction measuring 10 mm or more in
diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A
positive reaction does not mean that active disease is present, but it does
indicate exposure to TB or the presence of inactive (dormant) disease.
. Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike (negative and insignificant). To select from the
remaining options, note that the client has HIV, which will assist in directing you
to the correct option. An area of induration is present, so the test results are not
indeterminate. Review the tuberculin skin test and the procedure for interpreting
the results if you had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Clinical Judgment, Evidence
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
, NUR MISC / Focus on Adult Health
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 494, 530). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
. 4.ID: 9477067466
. A nurse is interpreting a central venous pressure (CVP) reading from a client in
whom right ventricular failure has been diagnosed. From this diagnosis, the
nurse would expect that the most likely result is a pressure of:
A. 4 cm H2O
B. 8 cm H2O
C. 11 cm H2O
D. 14 cm H2O Correct
. Rationale: CVP measurements are used to monitor blood volume and the
adequacy of venous return to the heart. The CVP measures pressures from the
right atrium or central veins. The normal CVP is 7 to 12 cm H 2O. An increased
CVP reading may indicate right ventricular failure. A low CVP reading may
indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm
H2O are normal. A reading of 14 cm H2O is increased.
. Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the
pathophysiology of right ventricular failure and recalling the normal CVP reading
will direct you to the correct option. Review the normal CVP reading and the
expected findings in right ventricular failure if you had difficulty with this
question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Cardiovascular
. Giddens Concepts: Clinical Judgment, Perfusion
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 1608-1609). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
. 5.ID: 9477067454
. A nurse is caring for a client who has just undergone thyroidectomy. Which
technique is the bestway for the nurse to assess the surgical site for bleeding?
A. Asking the client whether the dressing feels wet
B. Looking for moisture on the top of the dressing
. ID: 9477061444
. A nurse is monitoring a client who is taking spironolactone for the treatment of
hypertension. Which findings denote adverse effects of the medication? Select
all that apply.
A. Constipation
B. Tall T waves Correct
C. Hyporeflexia
D. Shallow respirations
E. Prolonged PR interval Correct
F. Hyperactive bowel sounds Correct
. Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing
diuretics can cause hyperkalemia. Cardiovascular manifestations of
hyperkalemia include tall T waves, widened QRS complexes, prolonged PR
intervals, and flat P waves. Other cardiovascular manifestations include an
irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle
twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also
occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are
signs of hypokalemia.
. Test-Taking Strategy: The knowledge that spironolactone is a potassium-
sparing diuretic will assist you in determining that hyperkalemia is an adverse
effect of the medication. Recalling the manifestations of hyperkalemia will direct
you to the correct options. Also, note that the incorrect options are comparable
or alike in that they indicate a slowed body response or function. Review the
adverse effects of spironolactone and the manifestations of hyperkalemia if you
had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Pharmacology
. Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and
Electrolytes
. Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook
2015. (pp. 1125-1127) St. Louis: Saunders.
. Awarded 3.0 points out of 3.0 possible points.
. 2.ID: 9477057138
, NUR MISC / Focus on Adult Health
. A nurse is providing dietary instructions to a client with chronic obstructive
pulmonary disease (COPD) who is experiencing a loss of appetite and
complains of feeling “too full to eat.” What does the nurse encourage the client
to do? Select all that apply.
A. Avoid drinking fluids before and during meals Correct
B. Eat a variety of dark-green vegetables, such as broccoli
C. Have snacks, such as crackers and cheese, between meals
D. Select foods that are easy to chew and are not gas forming Correct
E. Consume high-calorie drinks, such as milkshakes, between meals
. Rationale: COPD is a progressive and irreversible condition characterized by
diminished inspiratory and expiratory capacity of the lungs. Instruct the client
who complains of feeling too full to eat, to avoid drinking fluids before and
during the meal. Dry foods such as crackers stimulate coughing; foods such as
milk and chocolate may increase the thickness of saliva and secretions. Cheese
is constipating and should also be avoided by the client. The nurse should also
teach the client about foods that are easy to chew and do not encourage the
formation of gas; for this reason, broccoli, which is a gas-forming food, should
be avoided.
. Test-Taking Strategy: Use the process of elimination. Recalling that milk may
increase the thickness of saliva will assist you in eliminating the option that
encourages the consumption of milkshakes. Eliminate the option in which the
consumption of broccoli is encouraged, because it is a gas-forming food. To
select from the remaining options, note the strategic words “too full to eat” in the
question and the option that encourages the client to avoid fluids before and
during meals; this will direct you to the correct answers. Review dietary
measures for the client with COPD if you had difficulty with this question.
. Level of Cognitive Ability: Applying
. Client Needs: Physiological Integrity
. Integrated Process: Teaching and Learning
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Gas Exchange, Nutrition
. HESI Concepts: Oxygenation/Gas Exchange, Metabolism – Nutrition
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 595-596). St. Louis: Mosby.
. Awarded 2.0 points out of 2.0 possible points.
. 3.ID: 9477057160
. A tuberculin skin test (TST) is administered to a client with a diagnosis of HIV
,NUR MISC / Focus on Adult Health
infection. Forty-eight hours after administration, the nurse checks the test site
(see image).
.
. The nurse documents the result of the test as:
A. Positive Correct
B. Negative
C. Insignificant
D. Indeterminate
. Rationale: The tuberculin, or TST, test is a reliable determinant of tuberculosis
(TB) infection. A reaction measuring 5 mm or more in diameter is considered
positive in a client with HIV infection. A reaction measuring 10 mm or more in
diameter is considered positive in a non-immunosuppressed client. In this
instance, the area of induration measures 9 mm, indicating a positive reaction. A
positive reaction does not mean that active disease is present, but it does
indicate exposure to TB or the presence of inactive (dormant) disease.
. Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike (negative and insignificant). To select from the
remaining options, note that the client has HIV, which will assist in directing you
to the correct option. An area of induration is present, so the test results are not
indeterminate. Review the tuberculin skin test and the procedure for interpreting
the results if you had difficulty with this question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Respiratory
. Giddens Concepts: Clinical Judgment, Evidence
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Evidence-Based
Practice/Evidence
, NUR MISC / Focus on Adult Health
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 494, 530). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
. 4.ID: 9477067466
. A nurse is interpreting a central venous pressure (CVP) reading from a client in
whom right ventricular failure has been diagnosed. From this diagnosis, the
nurse would expect that the most likely result is a pressure of:
A. 4 cm H2O
B. 8 cm H2O
C. 11 cm H2O
D. 14 cm H2O Correct
. Rationale: CVP measurements are used to monitor blood volume and the
adequacy of venous return to the heart. The CVP measures pressures from the
right atrium or central veins. The normal CVP is 7 to 12 cm H 2O. An increased
CVP reading may indicate right ventricular failure. A low CVP reading may
indicate hypovolemia. A reading of 4 cm H2O is low. Readings of 8 and 11 cm
H2O are normal. A reading of 14 cm H2O is increased.
. Test-Taking Strategy: Focus on the client’s diagnosis. Thinking about the
pathophysiology of right ventricular failure and recalling the normal CVP reading
will direct you to the correct option. Review the normal CVP reading and the
expected findings in right ventricular failure if you had difficulty with this
question.
. Level of Cognitive Ability: Analyzing
. Client Needs: Physiological Integrity
. Integrated Process: Nursing Process/Assessment
. Content Area: Adult Health/Cardiovascular
. Giddens Concepts: Clinical Judgment, Perfusion
. HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion/Clotting
. Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed., pp. 1608-1609). St. Louis: Mosby.
. Awarded 1.0 points out of 1.0 possible points.
. 5.ID: 9477067454
. A nurse is caring for a client who has just undergone thyroidectomy. Which
technique is the bestway for the nurse to assess the surgical site for bleeding?
A. Asking the client whether the dressing feels wet
B. Looking for moisture on the top of the dressing
