Test Yourself Quiz
Question 1
pts
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.
“I should continue with my physical therapy and walking.”
Correct!
“Avoiding pain medication will prevent constipation.”
“I should empty my bladder when I feel the urge.”
Correct!
“I should drink plenty of liquids like iced tea or coffee.”
Correct!
“Limiting fiber is necessary to avoid diarrhea.”
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.
Question 2
pts
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.
Correct!
Encourage family members to obtain a tuberculosis skin test.
Correct!
Provide culturally sensitive education.
Provide written instructions in English for the client to reference.
Correct!
Urge all family and close contact community members to seek and complete treatment
to enhance compliance.
Encourage the client and family to wash all dishes by hand to prevent the spread of
infection.
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.
Question 3
pts
The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm
(refer to figure). What is the initial nursing action?
Correct!
Check for a pulse
Begin cardiopulmonary resuscitation (CPR)
Notify the health care provider
Obtain a 12 lead electrocardiogram (ECG)
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.
Question 4
0. pts
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.
Correct!
Environmental exposure to toxins
Correct Answer
Income
Age
Correct!
Low birth weight
Correct!
Chronic illness
Question 1
pts
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.
“I should continue with my physical therapy and walking.”
Correct!
“Avoiding pain medication will prevent constipation.”
“I should empty my bladder when I feel the urge.”
Correct!
“I should drink plenty of liquids like iced tea or coffee.”
Correct!
“Limiting fiber is necessary to avoid diarrhea.”
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.
Question 2
pts
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.
Correct!
Encourage family members to obtain a tuberculosis skin test.
Correct!
Provide culturally sensitive education.
Provide written instructions in English for the client to reference.
Correct!
Urge all family and close contact community members to seek and complete treatment
to enhance compliance.
Encourage the client and family to wash all dishes by hand to prevent the spread of
infection.
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.
Question 3
pts
The nurse is observing the cardiac monitor of a client and notes this cardiac rhythm
(refer to figure). What is the initial nursing action?
Correct!
Check for a pulse
Begin cardiopulmonary resuscitation (CPR)
Notify the health care provider
Obtain a 12 lead electrocardiogram (ECG)
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.
Question 4
0. pts
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.
Correct!
Environmental exposure to toxins
Correct Answer
Income
Age
Correct!
Low birth weight
Correct!
Chronic illness
