D

Module 7 Exam
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. Spaghetti with fresh tomatoes Correct
B. Boiled lobster with baked potato
C. Grilled chicken with turnip greens Correct
D. Instant hot cereal with bacon
E. Tomato soup with a ham sandwich Incorrect

Rationale: Foods that are lower in sodium include fruits and vegetables, which do not contain physiologic saline. Fresh poultry and
pastas are also low in sodium. Highly processed and refined foods and luncheon meats are high in sodium unless they are
specifically labeled “low sodium.” Saltwater fish and shellfish are higher in sodium.
Test-Taking Strategy: Focus on the subject, selecting low-sodium foods. Begin to answer this question by eliminating boiled lobster
with baked potato, because saltwater fish and shellfish are high in sodium. Next eliminate the options that contain processed foods
and luncheon meats. Review: foods that are high and low in sodium
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
Giddens Concepts: Client Education, Nutrition
HESI Concepts: Health, Wellness, and Illness, Teaching and Learning/Patient Education
References: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., p. 141). 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 2.0 possible points.
2. 2.ID: 9477010158
A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to
the nurse that the client needs additional instruction? Select all that apply.
A. Carrots
B. Tapioca Incorrect
C. Scallops Correct
D. Broccoli
E. Chicken liver Correct

Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from
the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible
amounts of purines and may be consumed freely by the client with gout.
Test-Taking Strategy: Note the strategic words “needs additional instruction,” which indicate a negative event query and the need
to select foods that are unacceptable for this client. Recalling foods that are high in purines will direct you to the correct options.
Review: dietary measures for the client with gout
Integrated Process: Teaching and Learning
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. 1080, 1576). St. Louis: Mosby.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 442-443). St. Louis: Mosby.
3. 3.ID: 9477007734
A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the
client? Select all that apply.
A. Custard
B. Apple juice Correct
C. Orange juice Incorrect
D. Chicken broth Correct
E. Orange gelatin Correct
F. Vanilla ice cream

Rationale: A clear liquid diet consists of foods, such as apple juice, chicken broth, and gelatin, which are relatively transparent.
Custard, orange juice, and vanilla ice cream are components of a full liquid diet.
Test-Taking Strategy: Remembering that a clear liquid diet consists of foods that are relatively transparent will direct you to the
correct options. Review: the foods allowed on clear liquid and full liquid diets
Level of Cognitive Ability: Applying
Integrated Process: Nursing Process/Implementation
Giddens Concepts: Caregiving, Nutrition
HESI Concepts: Caregiving, Health, Wellness, and Illness
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 765). St. Louis: Mosby.
4. 4.ID: 9477011622
Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are
acceptable to eat while taking this medication? Select all that apply.
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.
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
B. High in fiber Correct
C. Low in residue Incorrect
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
Giddens Concepts: Client Education, Health Promotion
clinical problems (9thed., p. 995). St. Louis: Mosby.
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
C. Green olives Incorrect
D. Baked potato Correct
E. Fresh cherries 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
clinical problems (9thed., pp. 715-716). St. Louis: Mosby.
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
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
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. Spare ribs, rice, gelatin, tea
B. Pasta, garlic bread, ginger ale
C. Chicken breast, broccoli, strawberries, milk Correct
D. Peanut butter and jelly sandwich, chocolate cake, tea

Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and
strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin, jelly, tea, and ginger ale have no nutritional
value. Pasta, rice, and bread deliver complex carbohydrates. Spare ribs may contain some protein but are high in fat.
Test-Taking Strategy: Focus on the subject, food items that promote wound healing. Eliminate pasta, garlic bread, and ginger ale
first because it contains no fruits or vegetables. Review the food item presented in each option and recall that protein and vitamin C
are necessary for wound healing. This will assist in answering correctly. Review: foods high in protein and vitamin C
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of
9. 9.ID: 9476999160
A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the
client’s meal tray?
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.
Client Needs: Safe and Effective Care Environment
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.
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
Giddens Concepts: Client Education, Fluid and Electrolytes
HESI Concepts: Teaching and Learning/Patient Education, Fluid and Electrolytes
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 431-432). St. Louis:
Mosby.
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. Lying down after eating Correct
B. Eating high-protein foods Correct
C. Drinking liquids with meals
D. Eating six small meals per day Correct
E. Eating concentrated sweets during the day

Rationale: The client who has undergone partial gastrectomy is at risk for dumping syndrome. This client should be prescribed a
diet that is high in protein, moderate in fat, and low in carbohydrates. The client should lie down after meals and avoid drinking
liquids with meals. Frequent small meals are encouraged. The client should also avoid concentrated sweets.
Test-Taking Strategy: Focus on the subject, partial gastrectomy. Recall that this client is at risk for dumping syndrome. This will
direct you to the correct options: the actions that will assist to prevent the problems associated with dumping syndrome. Review
the dietary measures to prevent dumping syndrome
Content Area: Adult Health/Gastrointestinal
HESI Concepts: Teaching and Learning/Patient Education, Fluid and Electrolytes
12. 12.ID: 9477008736
A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the
client understands the prescribed regimen?
A. Chicken, potatoes, and cranberries
B. Spinach salad, milk, and a banana Correct
C. Peanut butter sandwich, milk, and prunes
D. Linguini with shrimp, tossed salad, and a plum Incorrect

Rationale: In an alkaline ash diet, all fruits are allowed except cranberries, prunes, and plums. The incorrect options represent
components of an acid ash diet.
Test-Taking Strategy: Focus on the subject, foods allowed on an alkaline ash diet. Knowledge of foods that are either included or
restricted in an alkaline ash diet is necessary to answer this question. Remembering that cranberries, prunes, and plums are not
allowed in an alkaline ash diet will direct you to the correct option. Review the foods allowed in an alkaline-ash and an acid-ash diet.
Giddens Concepts: Client Education, Elimination
HESI Concepts: Elimination, Teaching and Learning/Patient Education
Reference: Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 443-444). St. Louis: Mosby.
13. 13.ID: 9477002335
A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to
improve the client’s bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications
of pressure and skin breakdown?
A. Left heel
B. Scapulae Incorrect
C. Right heel Correct
D. Back of the head

Rationale: Certain areas are under pressure and at risk for breakdown in the client who is in skeletal traction. These areas include
the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg, which is used as a brace when the
client pushes up from the bed). Other such pressure points include the ischial tuberosity, popliteal space, and Achilles tendon.
Test-Taking Strategy: Note the subject, “high-risk area” and “pressure and skin breakdown.” Visualize the client in the question.
Eliminate the left heel and the back of the head, because the heel is immobilized and the client can lift the head if a trapeze is in
use. Eliminate the scapulae next, because the client is also able to lift this area from the mattress with the use of the trapeze as well.
Knowing that the unaffected heel is used to push into the mattress will direct you to the correct option. Review care of the client in
skeletal traction
Level of Cognitive Ability: Analyzing
Integrated Process: Nursing Process/Assessment
Content Area: Adult Health/Musculoskeletal
Giddens Concepts: Clinical Judgment, Tissue Integrity
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Tissue Integrity
14. 14.ID: 9477006347
Which food should the nurse offer to a client who has been prescribed a full liquid diet?
A. Toast
B. Plain bagel
C. Cooked custard Correct
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
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Health, Wellness, and Illness
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. Smoked ham, fresh carrots, boiled potato Incorrect
B. Hot dog in a bun, sauerkraut, baked beans

C. Turkey, baked potato, salad with oil and vinegar Correct
D. Shrimp, baked potato, salad with blue cheese dressing

Rationale: Foods that are high in sodium should be limited in the diet of the client with hypertension and heart failure. Foods in the
meat group that are higher in sodium include bacon, luncheon meat, chipped or corned beef, ham, hot dogs, kosher meat, smoked
or salted meat or fish, and a variety of shellfish. These foods should be avoided or strictly limited for hypertensive clients.
Test-Taking Strategy: Focus on the subject, diet for the client with heart failure and hypertension. Recalling that the client with
hypertension and heart failure needs to limit sodium in the diet. Eliminate the hot dog and smoked ham first because they are
highly processed meats. (Sauerkraut is also high in sodium.) Eliminate the menu consisting of shrimp and salad with blue cheese
dressing next, because shellfish and commercial dressings are high in sodium. Review foods high in sodium
Content Area: Adult Health/Cardiovascular
HESI Concepts: Fluids and Electrolytes, Health, Wellness, and Illness
clinical problems (9thed., pp. 715, 777-778). St. Louis: Mosby.
16. 16.ID: 9477007722
The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which
foods are allowed in the diet of the client taking phenelzine? Select all that apply.
A. Peas Correct
B. Broccoli Correct
C. Potatoes Correct
D. Red wine
E. Avocados Incorrect
F. Cereal with raisins

Rationale: Because phenelzine is an MAOI, the client should avoid foods that are high in tyramine, which could trigger a potentially
fatal hypertensive crisis. Foods to avoid include aged cheeses, smoked or processed meats, red wines, beer, and certain fruits,
including avocados, raisins, and figs. Vegetables, with the exception of broad-bean pods, are generally acceptable.
Test-Taking Strategy: Focus on the subject, foods allowed for a client taking a MAOI. Recalling that foods that contain tyramine
must be avoided by the client taking an MAOI will help direct you to the correct options. Review client teaching points for MAOIs
Content Area: Pharmacology
Giddens Concepts: Client Education, Safety
HESI Concepts: Teaching and Learning/Patient Education, Safety
Rosenjack Burchum, Rosenthal (2016) pp. 362-363
17. 17.ID: 9477008764
A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the
client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from
the diet?
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
Reference: Rosenjack Burchum, Rosenthal (2016) pp. 1196-1197
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
E. Orange juice Incorrect

Rationale: The client taking a medication to treat hypocalcemia should be instructed to avoid excessive consumption of spinach,
rhubarb, bran, and whole-grain cereals, all of which may limit calcium absorption. Good dietary sources of calcium include milk
products, dark-green leafy vegetables, clams, oysters, sardines, and orange juice fortified with calcium.
Test-Taking Strategy: Focus on the subject, foods that can interfere with calcium absorption. Thinking about each food listed and
how it might affect calcium absorption will direct you to the correct options. Review the foods high in calcium
Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 1280) St. Louis: Saunders.
19. 19.ID: 9477007773
The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client
understands the instructions when the client states to limit consumption of which items?
A. Coffee, cola, and chocolate Correct
B. Oysters, lobster, and shrimp
C. Apples, oranges, and pineapple
D. Cottage cheese, cream cheese, and dairy creamers

Rationale: Theophylline is a methylxanthine bronchodilator, and the nurse teaches the client to limit the intake of xanthine-
containing foods while taking this medication. These foods include coffee, tea, cola, and chocolate. The items in the remaining
options are acceptable to consume.
Test-Taking Strategy: Focus on the subject, foods to avoid when taking theophylline. Recall that theophylline is a methylxanthine
bronchodilator and that intake of excessive amounts of foods naturally high in xanthines should be avoided. With this in mind, use
knowledge about the foods high in xanthine to eliminate the incorrect options. Review theophylline and the foods naturally high in
xanthines
References: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (p. 1180) St. Louis: Saunders.
Rosenjack Burchum, Rosenthal (2016) pp. 937-938
20. 20.ID: 9477007703
A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the
foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while
taking this medication?
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
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
21. 21.ID: 9477011664
For which vitamin deficiency should the nurse monitor the client who is on a vegan diet?
A. Vitamin A
B. Vitamin B12 Correct
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
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.
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. One low in protein Correct
B. One high in fluids
C. One high in carbohydrates
D. One with a moderate amount of fat

Rationale: A low-protein diet would be prescribed for the client with cirrhosis who has an increased ammonia level. Protein in the
diet is transported to the liver by the portal vein after digestion and absorption. The liver breaks down protein, resulting in the
formation of ammonia. Therefore the client would benefit from a low-protein diet.
Test-Taking Strategy: Focus on the subject, the best diet for the client with an increased ammonia level. Recall the physiology of the
liver to answer this question. Recalling that the breakdown of protein results in the formation of ammonia will direct you to the
correct option. Review diet therapy for the client with cirrhosis and a high ammonia level
Integrated Process: Nursing Process/Planning
Giddens Concepts: Cellular Regulation, Nutrition
HESI Concepts: Cellular Regulation, Health, Wellness, Illness
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1304).
St. Louis: Saunders.
23. 23.ID: 9477006326
A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the
client understands the instructions?
A. Roast turkey with a baked potato Correct
B. Fruit plate with fresh whipped cream
C. Fried chicken with macaroni and cheese
D. Barbecued spare ribs with buttered noodles

Rationale: The client with cholecystitis should reduce intake of fat. Foods that should generally be avoided to achieve this end
include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. Therefore the correct answer
is roast turkey with a baked potato, which is a meal low in fat.
Test-Taking Strategy: Focus on the subject, the appropriate diet for the client with cholecystitis. Think about the pathophysiology of
this disorder and that fat needs to be eliminated or limited in the diet. Eliminate barbecued spare ribs with buttered noodles and
fried chicken with macaroni and cheese because they are comparable or alike in that they contain fat. Next eliminate the fruit plate
with fresh whipped cream, because fresh whipped cream is high in fat. Review the appropriate dietary measures for the client with
cholecystitis
Giddens Concepts: Inflammation, Nutrition
HESI Concepts: Inflammation, Health, Wellness, Illness
24. 24.ID: 9477002348
A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed
while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the
instructions?
A. Milk
B. Cabbage Incorrect
C. Boiled potatoes Correct
D. Coffee with cream

Rationale: During remission, the client must avoid intestinal stimulants such as alcohol, caffeinated beverages, high-fat foods, gas-
forming foods, milk products, and foods such as raw fruits and some vegetables, that are very high in fiber. Vitamins and iron
supplements may be prescribed.
Test-Taking Strategy: Note the strategic word, best. Focus on the subject, the diet for a client with ulcerative colitis in remission.
Think about the pathophysiology associated with this disorder. First eliminate coffee with cream and milk, knowing that coffee is a
stimulant and milk may aggravate diarrhea. Remember, as you select from the remaining options, that a diet with lower fiber
minimizes irritation of ulcerated bowel tissue. Review dietary measures for the client with ulcerative colitis
Giddens Concepts: Elimination, Inflammation
HESI Concepts: Elimination, Inflammation
25. 25.ID: 9477005768
A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods
listed on the client’s shopping list indicate to the nurse that the client has understood the information? Select all that apply.
A. Eggs
B. Yogurt Correct
C. Parsley Correct
D. Broccoli
E. Cucumbers Incorrect
F. Cranberry juice Correct

Rationale: Deodorizing foods for the client with an ostomy include beet greens, parsley, buttermilk, cranberry juice, and yogurt.
Eggs, broccoli, and cucumbers are gas-forming foods.
Test-Taking Strategy: Focus on the subject, measures to control stool odor. Recalling the effects of various foods on the
gastrointestinal tract will direct you to the correct options. Review the foods that cause odor or gas and those that have a
deodorizing effect.
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 1252-
1253). St. Louis: Saunders.
Giddens Concepts: Elimination, Self-Management
HESI Concepts: Elimination; Health, Wellness, and Illness
26. 26.ID: 9477010118
A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food that just
arrived on the client’s meal tray should the nurse discourage the client from eating?
A. Bran Correct
B. Pasta
C. Boiled rice
D. Low-fat cheese Incorrect

Rationale: Ileostomy output is liquid. The addition or elimination of various foods can help thicken this liquid drainage. Bran is high
in dietary fiber and will therefore increase the output of liquid stool by hastening its propulsion through the bowel. Foods that help
thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese.
Test-Taking Strategy: Focus on the subject, foods that can produce liquid stools. Note that the client has an ileostomy. Recalling
that high-fiber foods such as bran can speed propulsion of stool through the bowel will direct you to the correct option. Review the
foods that should be avoided by the client with an ileostomy
Giddens Concepts: Elimination, Fluid and Electrolytes
HESI Concepts: Elimination, Fluids and Electrolytes
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., p. 1279). St.
Louis: Saunders.
27. 27.ID: 9477011634
A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food
does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client?
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
Content Area: Adult Health/Oncology
Giddens Concepts: Cellular Regulation, Nutrition
HESI Concepts: Cellular Regulation, Metabolism-Nutrition
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. Not eating ice cream for 2 days
B. Omitting 8 oz (240 ml) of skim milk from that meal Correct
C. Omitting salad dressing and butter at lunchtime
D. Eating only half of an allowed meat product at supper

Rationale: Yogurt is a milk product. Therefore if the client is going to eat 8 oz (240 ml) of yogurt at a meal, the client should
eliminate the milk product from the same meal. Ice cream is not recommended for the diabetic diet because it is high in fat and
sugar. Meat is not a milk product, and it is unnecessary to alter the meat allowance at suppertime. Salad dressing and butter are
fats.
Test-Taking Strategy: Focus on the subject, the food exchange system for a client with diabetes mellitus. Note the information in
the question, which indicates that the client wants to eat 8 oz (240 ml) of yogurt, will direct you to the correct option. Remember
that yogurt is a milk product. Review dietary management of diabetes mellitus
Content Area: Adult Health/Endocrine
Giddens Concepts: Glucose Regulation, Nutrition
HESI Concepts: Health, Wellness, and Illness, Metabolism – Glucose Regulation
29. 29.ID: 9477006310
A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the
disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has
the best understanding of the material if the client states to increase the intake of which foods? Select all that apply.
A. Milk
B. Peanuts Correct
C. Chicken
D. Broccoli Incorrect
E. Asparagus Correct
F. Whole-grain cereals Correct

Rationale: Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin, but
other good sources are peanuts, asparagus, legumes, and whole-grain and enriched cereals. Milk is high in vitamins A and D,
calcium, and magnesium. Chicken is high in protein. Broccoli is high in calcium and folic acid.
Test-Taking Strategy: Note the strategic word, best. Focus on the subject, foods that are high in thiamine. Remember that such
foods as peanuts, asparagus, legumes, and whole-grain and enriched cereals are good sources of thiamine. Review the foods that
are high in thiamine
HESI Concepts: Teaching and Learning/Patient Education, Metabolism – Nutrition
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 109, 119). St. Louis: Mosby.
30. 30.ID: 9477000395
A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine
the effectiveness of the tube feedings?
A. Daily weight Correct
B. Serum protein level
C. Calorie count sheets Incorrect
D. Daily intake and output records

Rationale: The most accurate measurement of the effectiveness of nutritional management of the client is the daily weight. The
client should be weighed at the same time (preferably early morning) each day, wearing the same clothes, on the same scale. The
incorrect options may be used to assess nutrition and hydration status, but the effectiveness of the diet is measured by whether the
client’s body weight is maintained.
Test-Taking Strategy: Note the strategic word “effectiveness.” This tells you that the correct option is an outcome rather than a tool
for measuring the outcome. With this in mind, eliminate calorie count sheets and daily intake and output records, because these
are tools used by the nurse to measure nutritional and fluid status. Eliminate the serum protein level next, because it reflects only
one component of the diet, protein. Review methods of monitoring nutritional intake.
Giddens Concepts: Evidence, Nutrition
HESI Concepts: Evidence-Based Practice/Evidence, Metabolism-Nutrition
31. 31.ID: 9477000353
A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need
for further instruction?
A. “I need to eat foods high in calcium.”
B. “How I eat can affect my baby’s growth.”
C. “I need to take vitamins throughout my pregnancy.”
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.
Content Area: Maternity/Antepartum
HESI Concepts: Health, Wellness, and Illness – Health Promotion, Teaching and Learning/Patient Education
Reference: Lowdermilk et al (2016) pp. 317, 345-346
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
Giddens Concepts: Elimination, Nutrition
HESI Concepts: Elimination, Metabolism- Nutrition
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
E. Kidney beans Correct
F. Refined white bread

Rationale: The client with iron-deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of
dietary iron are red meat, liver, and other organ meats, blackstrap molasses, and oysters. Other good sources are kidney beans,
soybeans, lentils, whole-wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.
Test-Taking Strategy: Focus on the subject, foods high in iron. It is necessary to know which foods are high in iron to answer
correctly. Review foods high in iron
HESI Concepts: Teaching and Learning/Patient Education, Metabolism-Nutrition
34. 34.ID: 9476998563
A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which
menu choice by the client indicates to the nurse that the client needs further instruction?
A. Fish
B. Spinach
C. Rhubarb
D. American cheese Correct

Rationale: The client’s laboratory value reflects hypernatremia; the normal serum sodium range is 135 to 145 mEq/L (135-145
mmol/L). On the basis of this finding, the nurse would instruct the client to avoid foods high in sodium. These would include foods
from animal sources, which contain physiological saline (e.g., cheese, highly processed meats), and other foods that have sodium
added as a preservative. Spinach and rhubarb are good food sources of calcium. Fish is high in phosphorus.
Test-Taking Strategy: Note the strategic words “needs further instruction,” which indicate a negative event query and the need to
select the incorrect option. First determine that the client’s serum sodium level indicates hypernatremia and then identify the food
that is high in sodium. Eliminate spinach and rhubarb first because they are vegetables, and fruits and vegetables are low in sodium.
Select from the remaining options by recalling that cheese is a dairy product and high in sodium. Review foods high in sodium
Content Area: Fluids and Electrolytes
HESI Concepts: Fluids and Electrolytes, Metabolism-Nutrition
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 180-
35. 35.ID: 9477003570
A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which
menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction?
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.
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
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.
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?
A. Rice and fish
B. Eggs and bacon
C. Cereals and broccoli
D. Meats and citrus fruits Correct

Rationale: The nurse teaches the client with tuberculosis to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C
include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and
turnip greens. Liver and other meats, from which 10% to 30% of available iron is absorbed, are good choices. Less than 10% of iron
is absorbed from eggs and less than 5% from grains and vegetables.
Test-Taking Strategy: Recalling that the diet for the client with tuberculosis should be high in protein, vitamin C, and iron will assist
you in answering this question. It is also necessary to know which foods contain these various nutrients. Review nutrition for the
client with tuberculosis.
Content Area: Adult Health/Respiratory
HESI Concepts: Teaching and Learning/Patient Education, Metabolism-Nutrition
Louis: Saunders.
37. 37.ID: 9477012917
A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which
instruction?
A. To increase the intake of legumes Correct
B. That seafood should be included in the diet
C. That organ meats should be included in the diet
D. To have at least one serving each day of a citrus fruit Incorrect

Rationale: Dietary instructions to the client with a uric acid type stone include increasing consumption of legumes, green
vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should
also be instructed to decrease intake of purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.
Test-Taking Strategy: Focus on the subject, a client with a uric acid stone. Recalling that the goal is to increase the alkalinity of the
urine will assist in directing you to the correct option. Review dietary instructions associated with uric acid renal calculi.
Content Area: Adult Health/Renal and Urinary
38. 38.ID: 9477007779
The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a
complete bed bath. The nurse would intervene if the nurse observed the UAP doing which?
A. Washing the client’s feet
B. Washing the client’s chest Incorrect
C. Giving the client a back rub
D. Asking the client to wash his arms Correct

Rationale: A complete bed bath is for clients who are totally dependent and require total hygiene care. Total care may be necessary
for a client recovering from a myocardial infarction as a means of conserving client energy and reduce oxygen requirements. The
nurse would intervene if the CNA asked the client to wash his arms. The other options are components of a complete bed bath.
Test-Taking Strategy: Focus on the subject, the need for the nurse to intervene. Note that the options of washing the client’s feet
and chest are comparable or alike and eliminate these options. To select from the remaining options, recall that a client who is to
have a complete bed bath is not participating in any aspect of hygienic care; this will direct you to the correct option. Review the
procedure for administering a complete bed bath
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. 399-400). St. Louis: Mosby.
39. 39.ID: 9477000362
A nurse asks an unlicensed assistive personnel (UAP) to provide afternoon care to a client. The nurse expects that the UAP will take
which action?
A. Give the client a complete bed bath
B. Ask the client whether he would like to wash his face
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
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
B. Provide mouth care and perineal care only
C. Let the client decide what she wants washed
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
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?
A. Giving the client a complete bed bath Correct
B. Pulling the room curtains around the bathing area
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
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?
A. Is unable to produce urine Incorrect
B. Is voiding large amounts of urine
C. Has difficulty with leakage of urine
D. Has a diminished capacity to form urine Correct

Rationale: Oliguria, diminished capacity to form urine, is most often the result of a decrease in renal perfusion. Anuria is the inability
to produce urine. Polyuria is the voiding of excessively large amounts of urine. Urinary incontinence is the involuntary loss of urine.
Test-Taking Strategy: Focusing on the subject, oliguria, and using your knowledge of medical terminology will direct you to the
correct option. Review the description of oliguria
Content Area: Elimination
Giddens Concepts: Caregiving, Elimination
HESI Concepts: Caregiving, Elimination
43. 43.ID: 9477010108
A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should
provide which information to the mother?
A. That she may start bladder training at any time
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.
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.
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
D. Ureterovesical junction Correct

Rationale: The ureterovesical junction is the point where the ureters enter the bladder. At this junction, the ureter runs obliquely for
1.5 to 2 cm through the bladder wall before opening into the bladder. This pathway prevents the reflux of urine back into the ureter,
in essence acting as a valve to prevent urine from traveling back into the ureter and up to the kidney. The urethra extends from the
bladder to the opening of the body where urine is excreted. The nephrons and glomeruli are located in the kidneys.
Test-Taking Strategy: Note the strategic words, most closely. Note that the client has a bladder infection and focus on the subject,
extension of the infection to the kidneys. Visualizing the anatomy of the renal system will direct you to the correct option. Review
the anatomy of the kidney
Giddens Concepts: Elimination, Infection
HESI Concepts: Elimination, Infection
45. 45.ID: 9477002375
A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related
factors does the nurse recognize as increasing blood flow to the kidneys?
A. Physiological stress
B. Release of dopamine Correct
C. Release of norepinephrine
D. Sympathetic nervous system stimulation Incorrect

Rationale: Release of dopamine exerts a vasodilating effect on the renal arteries, improving renal function and increases urine flow.
The factors set forth in the other options result in renal vasoconstriction.
Test-Taking Strategy: Remember that options that are comparable or alike are not likely to be correct. With this in mind, eliminate
physiological stress and sympathetic nervous system stimulation. Eliminate release of norepinephrine next, because it is a
vasoconstricting substance. Review the concepts involved in blood flow to the kidneys
Giddens Concepts: Caregiving, Elimination
HESI Concepts: Caregiving, Elimination
Reference: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 818,
46. 46.ID: 9477008757
A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal
aging process?
A. Tubular reabsorption increases.
B. Urine-concentrating ability increases.
C. Glomerular filtration rate (GFR) is diminished. Correct
D. Medications are metabolized in larger amounts.

Rationale: As part of the normal aging process, the GFR decreases, like all of the other functional capabilities of the kidney. The
kidneys’ capacity to metabolize medications diminishes. Tubular reabsorption and urine-concentrating capacity also decrease.
Test-Taking Strategy: Focus on the subject, the normal aging process. Recalling that the aging process causes a decline in
functioning in many areas of the body will direct you to the correct option. Review the effects of aging on the renal system
Content Area: Developmental Stages
47. 47.ID: 9477006374
An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the
clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness?
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
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?
A. Increased sodium retention Incorrect
B. Increased sodium excretion Correct
C. Increased glucose retention
D. Increased magnesium excretion

Rationale: A serum potassium level of 5.8 mEq/L (5.8 mmol/L) is high, indicating potassium retention associated with the use of the
potassium-retaining diuretic. When potassium is retained, the kidneys excrete more sodium. The other options do not correctly
reflect the relationship between these two electrolytes.
Test-Taking Strategy: Focus on the data in the question and note the potassium level. To answer this question correctly, you must
first interpret the serum potassium reading correctly. After determining that the level is increased, representing potassium
retention, you would then recall the mechanisms that the kidneys use to maintain electrolyte balance. Review the the physiological
mechanisms in the kidneys that occur in response to electrolyte changes.
Level of Cognitive Ability: Understanding
Giddens Concepts: Cellular Regulation, Fluid and Electrolytes
HESI Concepts: Cellular Regulation, Fluids and Electrolytes
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 183-
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical
problems (9th ed., p. 1058). St. Louis: Mosby.
49. 49.ID: 9477012902
A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to
increase once the medication has had time to exert an effect on which structure in the kidney?
A. Distal tubule Incorrect
B. Loop of Henle Correct
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.
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.
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
Giddens Concepts: Elimination, Sleep
HESI Concepts: Elimination, Comfort
clinical problems (9thed., p. 1054, 1056). St. Louis: Mosby.
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. Has she been regularly exercising
B. Has she been experiencing headaches
C. Has she been having heavy menstrual cycles
D. Has she been drinking an excessive amount of coffee Correct

Rationale: Ingestion of certain foods directly affects urine production and excretion. Coffee, tea, cocoa, and cola, all of which
contain caffeine, promote increased urine formation. The incorrect options are not specifically related to the client’s complaint.
Test-Taking Strategy: Note the strategic words, most appropriately. Focus on the subject, an increase in urine output. Note the
relationship between the subject and the correct option, which is the only option related to fluid balance. Review the factors that
affect fluid balance
Content Area: Fluids & Electrolytes
Louis: Saunders.
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 896, 898). St. Louis: Mosby.
52. 52.ID: 9477005722
A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client’s urinary output and laboratory values,
anticipating which about the client?
A. Urine output will be decreased Correct
B. Urine production will be increased
C. Serum osmolality will be decreased Incorrect
D. Urine specific gravity will decreased

Rationale: A febrile client would be expected to have some degree of dehydration resulting from increased metabolic demands. In
response to dehydration, the body attempts to restore fluid balance by reducing urine production. The client who is diaphoretic
also loses a large amount of fluid through insensible water loss, which worsens dehydration and further decreases urine production.
Urine specific gravity is increased in the presence of dehydration; serum osmolality also increases, indicating hemoconcentration
related to dehydration.
Test-Taking Strategy: Focus on the information in the question. Noting that the client has a fever and is diaphoretic and recalling
that dehydration usually accompanies these conditions will direct you to the correct option. Review conditions that affect fluid
balance
Giddens Concepts: Fluid and Electrolytes, Thermoregulation
HESI Concepts: Fluids and Electrolytes, Thermoregulation
Louis: Saunders.
53. 53.ID: 9477007746
A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does
the nurse tell the client are most likely to acidify the urine? Select all that apply.
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.
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.
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?
A. Helping the client stand
B. Elevating the head of the bed 90 degrees
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
Giddens Concepts: Elimination, Safety
HESI Concepts: Elimination, Safety
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
C. 1500 to 2000 mL Incorrect
D. 2000 to 2500 mL Correct

Rationale: A client with normal renal function who does not have heart disease or other alterations requiring fluid restriction should
drink 2000 to 2500 mL daily.
Test-Taking Strategy: Focus on the information in the question. Noting that the client has no disorders requiring alteration in the
amount of fluids he consumes will direct you to the option of the greatest amount of fluid. Review measures to maintain normal
daily fluid intake
Louis: Saunders.
56. 56.ID: 9476999154
A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine specimen. What should
the nurse tell the client?
A. That she should douche before collecting the specimen
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.
Content Area: Infection Control
Giddens Concepts: Client Education, Infection
HESI Concepts: Teaching and Learning/Patient Education, Infection
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?
A. Intake 1600 mL, output 800 mL
B. Intake 1500 mL, output 1400 mL Correct
C. Intake 2400 mL, output 2900 mL
D. Intake 3000 mL, output 2400 mL

Rationale: The client’s urine output should be about the same as the intake during the same period. The only option that reflects
this balance is intake 1500 mL, output 1400 mL.
Test-Taking Strategy: Focus on the subject, an indication of proper fluid balance. Knowing that intake should be approximately the
same as output will help you eliminate each of the incorrect options. Review the concepts of fluid balance.
Giddens Concepts: Clinical Judgment, Fluid and Electrolytes
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes
Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 885). St. Louis: Mosby.
58. 58.ID: 9477005793
A health care provider states that a client’s insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to
reflect fluid loss occurring through which routes?
A. Wound drain and skin
B. Skin and mechanical ventilator Correct
C. Nasogastric tube and wound drain
D. Foley catheter and nasogastric tube

Rationale: Insensible fluid losses are those that cannot be measured because they occur through the skin and the lungs. They occur
on a daily basis, without the client’s awareness. Sensible losses are those that are measurable; they include wound drainage,
gastrointestinal tract losses, and urine output.
Test-Taking Strategy: Focus on the subject, “insensible fluid loss.” Recalling that insensible loss cannot be measured will direct you
to the correct option. Review sensible and insensible fluid loss
Louis: Saunders.
59. 59.ID: 9476999179
A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional
instruction if which is observed?
A. The client holds the cane close to the body
B. The client holds the cane on the unaffected side
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.
Giddens Concepts: Mobility, Safety
HESI Concepts: Mobility, Safety
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
B. Injury to the nerves Correct
C. An abnormal stance
D. A fall and further injury

Rationale: When crutches are correctly fitted, the tops are three to four fingerbreadths, or 1 to 2 inches (2.5 to 5 cm), from the
axillae. This ensures that the client’s axillae are not resting on the crutches or bearing the weight of the crutches, which could result
in injury to the nerves of the brachial plexus. The incorrect options are not the primary concerns in this situation.
Test-Taking Strategy: Eliminate the options that are comparable or alike (i.e., abnormal stance and fall and further injury) first. To
select from the remaining options, recall the risk of brachial nerve plexus injury with poorly fitted crutches, which will direct you to
the correct option. Review the complications associated with the use of crutches
61. 61.ID: 9477008725
A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client
places the crutches in which position?
A. 2 inches (5 cm) to the front and side of the toes Incorrect
B. 8 inches (20 cm) to the front and side of the toes

Correct
C. 15 inches (38 cm) to the front and side of the toes
D. 22 inches (56 cm) to the front and side of the toes.
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.
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
B. Rubber crutch tips will not slip, even when wet.
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
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?
A. Left hand, 6 inches (15 cm) lateral to the left foot

Correct
B. Right hand, 6 inches (15 cm) lateral to the right foot.

Incorrect
C. Left hand, placing the cane in front of the left foot
D. Right hand, placing the cane in front of the right foot

Rationale: The client is taught to hold the cane on the side opposite the weakness. This is because, in normal walking, the opposite
arm and leg move together (a.k.a. reciprocal motion). The cane also helps support the affected side as it moves forward and helps
the client maintain balance. The cane is placed 6 inches (15 cm) lateral to the fifth toe.
Test-Taking Strategy: Note the information in the question and that the client has right-sided weakness. Knowing that the cane is
held at the client’s side, not in front, helps you to eliminate these options first. Knowing that the preferred method is to have the
cane positioned on the stronger side will help you choose the correct option over the others that remain. Review client teaching
points for the use of a cane
64. 64.ID: 9477012964
A nurse is evaluating the client’s use of a cane for left-sided weakness. The nurse determines that the client needs further
teaching if the client is observed doing what?
A. Holds the cane on the right side
B. Moves the cane when the right leg is moved Correct
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
Content Area: Safety
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 240, 245-246). St. Louis:
Mosby.
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
B. Rolled bath blanket to prevent abduction while turning the client
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
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
References: Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing: Patient-centered collaborative care. (7th ed., pp. 329-330
). St. Louis: Saunders.
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?
A. Keeping the head of the bed flat Incorrect
B. Placing pillows beneath the full length of the legs

C. Using a log-rolling technique for repositioning
D. Having the client assist by using the overhead trapeze Correct

Rationale: In the safe care of a client after lumbar spinal fusion, the head of the bed is generally kept flat. The client is log-rolled
from side to side as prescribed. As a matter of surgeon preference, pillows may be placed under the entire length of the legs to
relieve tension on the lower back. The use of an overhead trapeze is contraindicated during the 48 hours after surgery because its
use could result in twisting of the spine.
Test-Taking Strategy: Focus on the subject, the action that would cause the nurse to intervene, which indicates the need to select
the incorrect action. After spinal surgery, all members of the healthcare team must use positioning techniques that will keep the
client’s spine in good alignment. Therefore log-rolling and keeping the head of the bed flat are eliminated. To select from the
remaining options, recall that using pillows under the length of the legs promotes slight flexion of the spine while helping prevent
pressure on the popliteal space, which predisposes to the client to thrombophlebitis. Using an overbed trapeze could allow the
client to twist the spine, which is directly contraindicated. Review care of the client after lumbar spinal fusion
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?
A. “I should bend at the knees to pick things up.”
B. “I need to increase the fiber and fluids in my diet.”
C. “I can strengthen my back muscles by swimming or walking.” Incorrect
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.
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
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?
A. Flexing the feet against a footboard Incorrect
B. Slightly elevating the foot of the bed Correct
C. Keeping the head of the bed elevated 45 degrees
D. Placing the bed in reverse Trendelenburg position

Rationale: In Buck’s extension traction, the counter traction is typically applied with the use of the client’s body and may be
augmented through elevation of the foot of the bed. Usually the foot of the bed is elevated on blocks or the bed is put in the
Trendelenburg position. For counter traction to be maintained, it is essential that the client not slide down in the bed. Therefore the
use of the high Fowler position is discouraged. A footboard is not used for the purpose of counter traction.
Test-Taking Strategy: Focus on the subject, providing counter traction. Visualize the traction setup and the description in each of
the options to answer correctly. Review the principles of traction and counter traction
70. 70.ID: 9477010138
A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client
complains of discomfort. The nurse should take which action?
A. Asking the client to take slow, deep breaths
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.
Giddens Concepts: Elimination, Pain
HESI Concepts: Elimination, Comfort-Pain
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?
A. Immediately inflate the balloon
B. Insert the catheter 2.5 to 5 cm and inflate the balloon Correct
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.
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
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?
A. The child should be able to control defecation at the age of 18 months
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
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 137). St. Louis:
Elsevier.
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. Limiting vegetable intake to one serving per day
B. Limiting whole grains to three servings per week
C. Providing cooked fruits such as prunes or apricots Correct
D. Including spicy foods in the diet to increase peristalsis

Rationale: Older clients often experience changes in the gastrointestinal system that result in impairment of digestion and
elimination. In addition, peristaltic action declines with age, and esophageal emptying slows. Therefore the client requires a diet
containing fiber to provide bulk for fecal material. Although some spicy foods can increase peristalsis, they can also cause
indigestion and diarrhea. Vegetables and whole grains are important sources of fiber, and their consumption should not be limited.
Cooked fruits such as prunes or apricots are high in fiber.
Test-Taking Strategy: Focus on the information in the question and note that the question addresses an older client. First eliminate
the options that include the word “limiting.” To decide between the remaining options, eliminate spicy foods, because these can
cause indigestion and diarrhea. Review dietary measures to promote bowel elimination
clinical problems (9thed., pp. 966-967, 969). St. Louis: Mosby.
75. 75.ID: 9477006384
A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the
plan? Select all that apply.
A. Providing privacy and time for defecation Correct
B. Assisting the client into a sitting position Correct
C. Limiting the amount of fiber in the client’s diet
D. Providing a cool drink before defecation time
E. Initiating defecation measures every day at the same time Correct
F. Administering a cathartic suppository a half-hour before defecation time Correct

Rationale: A bowel training program can help clients who still have some neuromuscular control after a stroke achieve control of
bowel reflexes and have normal defecation. The cornerstone of such a training program is a daily routine. First the client should be
encouraged to attempt to defecate at the same time each day after the trigger meal. Other measures include administering a daily
stool softener or a cathartic suppository at least a half-hour before defecation time, providing a hot drink or juice that will stimulate
peristalsis before defecation time, providing privacy and time for defecation, and assisting the client into a position that will
facilitate defecation (e.g., a sitting position). Dietary measures that can help the client achieve bowel-training success include
increased fiber intake (with the aim of 25 to 30 g of dietary fiber per day) and adequate dietary fluid intake.
Test-Taking Strategy: Focus on the subject, a bowel-training program. Think about the general measures that will assist in
promoting defecation. This will help you identify the correct options. Review measures for inclusion in a bowel-training program
Giddens Concepts: Elimination, Intracranial Regulation
HESI Concepts: Elimination, Intracranial Regulation
76. 76.ID: 9477012972
A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be
administered?
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
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?
A. Document the results Correct
B. Administer a second tap water enema Incorrect

C. Add soap suds to the enema bag and repeat the enema
D. Administer a Fleet enema, then a tap water irrigation

Rationale: Tap water is hypotonic, exerting a lower osmotic pressure than fluid in the interstitial space. After infusion into the colon,
tap water escapes from the bowel lumen into the interstitial space. The net movement of water is low. The infused volume
stimulates defecation before large amounts of water leave the bowel. Tap water enemas should not be repeated, because water
toxicity or circulatory overload may occur if a large amount of water is absorbed. Therefore the other options are incorrect. Also,
the nurse would not administer an additional enema, a soap suds enema, or a Fleet enema without a specific prescription to do so.
Test-Taking Strategy: Eliminate the incorrect options because they are comparable or alike in that they involve administering
another enema to the client. Review the procedures for administering enemas
Giddens Concepts: Clinical Judgment, Elimination
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Elimination
78. 78.ID: 9477003542
A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client?
A. Immediately expel the enema
B. Retain the enema for several hours Correct
C. Expect to defecate within 30 minutes
D. Expect to experience cramping induced by the solution Incorrect

Rationale: Oil retention enemas lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. The
amount of enema solution is small, and the client usually does not experience cramping. To enhance the action of the oil, the client
should retain the enema for several hours, if possible.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they involve expelling the enema immediately or
within 30 minutes. To select from the remaining options, note the relationship between the words “oil retention” in the question
and “retain” in the correct option. Review the procedure for administering an oil retention enema
79. 79.ID: 9477006367
A nurse is administering a high cleansing enema. At what level above the client’s hips should the nurse place the enema bag?
A. 4 inches (10 cm)

B. 8 inches (20 cm)
C. 10 inches (25.5 cm)

Incorrect
D. 18 inches (45.5 cm)

Correct
Rationale: The health care provider may prescribe a high or a low cleansing enema. In this context, high and low refer to the height
of the enema bag and hence the pressure at which the fluid is delivered. High enemas are given to cleanse the entire colon. A low
enema cleans only the rectum and sigmoid colon. With a high enema, the bag is raised 12 to 18 inches (30.5 to 45.5 cm) or slightly
higher above the hips. With a low enema, the nurse holds the bag 3 inches (7.5 cm) or less above the client’s hips.
Test-Taking Strategy: Focus on the information in the question. Noting the words “high cleansing enema” will direct you to the
correct option. Review the procedure for administering a high cleansing enema
80. 80.ID: 9477014204
The health care provider (HCP) prescribes “enemas until clear” for a client. The nurse has administered three enemas to the client,
but the client is still passing brown stool and fluid. Which action should the nurse take?
A. Notify the HCP Correct
B. Continue administering enemas until the fluid returns clear
C. Administer a glycerin suppository and then administer one more enema
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
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?
A. 1½ inches (3.8 cm)
B. 3 inches (7.5 cm)

Incorrect
C. 4 inches (10 cm)

Correct
D. 6 inches (15 cm)

Rationale: The nurse inserts the rectal tube slowly, pointing the tip of the tube in the direction of the client’s umbilicus. In an adult
client the tube is inserted 3 to 4 inches (7.5 to 10 cm), in a child 2 to 3 inches (5 to 7.5 cm), and in an infant 1 to 1½ inches (2.5 to 3.8
cm).
Test-Taking Strategy: Focus on the subject, the procedure for administering an enema.Thinking about the anatomy of the rectum of
an adult client will assist you in answering the question. Review the procedure for administering an enema
82. 82.ID: 9477008786
A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal
cramping. Which action should the nurse take?
A. Clamp the enema bag tubing Correct
B. Remove the enema tube and allow the client to rest
C. Stop the instillation and allow the client to expel the solution
D. Raise the enema bag to quickly finish instillation of the solution

Rationale: If the client complains of cramping during instillation of the enema solution, the nurse should either reduce the height of
the enema bag or clamp the tubing. Temporary cessation of instillation will alleviate the cramping. Raising the enema bag to
quickly finish instillation of the solution will worsen cramping. Removing the enema tube and allowing the client to rest and
stopping the instillation and allowing the client to expel the solution will each alter the effectiveness of the enema.
Test-Taking Strategy: Eliminate the options that are comparable or alike (in this case, the ones involving removal of the enema
tube) first. To select from the remaining options, focus on the subject and eliminate the option that contains the word “quickly.”
Review the procedure for administering an enema
83. 83.ID: 9477007760
A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client’s heart rate
before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the
procedure to allow the client to rest. During this time the nurse checks the client’s heart rate again and counts 82 beats per minute.
The nurse should take which action?
A. Contact the health care provider
B. Discontinue the digital removal procedure
C. Continue the digital removal procedure Correct
D. Wait 1 hour and then continue the digital removal procedure

Rationale: Excessive rectal manipulation may cause irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which
may result in a reflexive slowing of the heart rate. The nurse would reassess the client’s heart rate during the procedure. If the heart
rate drops significantly or the cardiac rhythm changes, the nurse must stop the procedure. A change in heart rate from 88 to 82
beats per minute is not significant; therefore the nurse would continue the procedure.
Test-Taking Strategy: Focus on the data in the question. Note that the heart dropped by only 6 beats. This will help direct you to the
correct option. Review the procedure for digital fecal removal
84. 84.ID: 9477000372
A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in
the plan of care?
A. Offering the client a sleeping pill at night
B. Providing the client with a snack at bedtime
C. Asking the client what is done to prepare for sleep Correct
D. Leaving the television in the client’s room on at a very low volume

Rationale: Initially the nurse would ask the client what she does to prepare for sleep. Before implementing any intervention, the
nurse must assess the client’s habits to determine which are beneficial and which might hinder sleep. For this reason, the other
options are incorrect. A snack may or may not be helpful to the client. Even at a low volume, the television may constitute a
distraction for the client. Medication should be used only as a last measure and requires a prescription.
Test-Taking Strategy: Note the strategic word, initial. Use the steps of the nursing process to answer the question. The only option
that addresses assessment is the correct choice. Review care of the client who has difficulty sleeping
Content Area: Rest and Sleep
Giddens Concepts: Clinical Judgment, Sleep
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Comfort
85. 85.ID: 9477002325
A home care nurse makes a visit to a new mother who delivered a 7-lb (3.1 kg) girl 72 hours ago. The mother tells the nurse that her
newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother?
A. “Most newborns sleep about 16 hours a day” Correct
B. “We should probably have the baby checked out by the doctor.”
C. “If you see any other neurological alterations, call the pediatrician.”
D. “It’s important to wake the baby every hour to provide stimulation.”

Rationale: Between birth and 3 months, an infant averages 16 hours of sleep a day. Therefore this newborn’s sleep pattern is
normal. It is not necessary to wake the newborn every hour to provide stimulation.
Test-Taking Strategy: Note the strategic words, most appropriately. Eliminate the options that are comparable or alike in that they
indicate that the newborn is experiencing a neurological problem. To select from the remaining options, recall the normal sleep
pattern of the newborn, which will direct you to the correct option. Review the newborn sleep pattern
Giddens Concepts: Development, Sleep
HESI Concepts: Developmental, Comfort
86. 86.ID: 9477008779
An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which
information should the nurse provide to the client?
A. She should avoid napping during the day Incorrect
B. The only thing that will help is a sleeping pill
C. This is a normal occurrence as a person gets older Correct
D. She needs to stay up later at night to prevent these awakenings

Rationale: The total amount of sleep a person needs does not change with increasing age. However, the quality of sleep appears to
deteriorate for many older adults, giving rise to complaints of feeling less rested. An older adult awakens more often during the
night than a younger person does, and it may take an older adult longer to fall asleep. Therefore the other options are incorrect.
Additionally, measures other than medication should be implemented to promote rest and sleep.
Test-Taking Strategy: First, eliminate the option that contains the closed-ended word “only.” To select from the remaining options,
recall aging-related changes in the sleep pattern, which will direct you to the correct option. Review sleep pattern changes in the
older adult
Giddens Concepts: Development, Sleep
HESI Concepts: Developmental, Comfort
87. 87.ID: 9476999191
A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all
that apply.
A. Exercise just before bedtime.
B. Drink a glass of wine at bedtime.
C. Drink a cup (236 ml) of black tea before bedtime
D. Adjust the room temperature to a comfortable level. Correct
E. Eliminate lights, noise, and other environmental distractions. Correct
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
Giddens Concepts: Client Education, Sleep
HESI Concepts: Teaching and Learning/Patient Education, Comfort
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
C. Muscle relaxation techniques Correct

D. Traditional Chinese medicine
Rationale: A simple technique such as muscle relaxation can help ease any existing anxiety and promote sleep. In acupuncture,
special needles are inserted into specific points on the body as a means of modifying the perception of pain, normalizing
physiological function, or preventing or treating disease. Traditional Chinese medicine is focused on restoring and maintaining a
balanced flow of vital energy; interventions in this discipline include acupressure, acupuncture, herbal therapies, diet, meditation,
and tai chi and qigong (forms of exercise focused on breathing, visualization, and movement). Herbal therapy involves the use of
herbs (plants or plant parts). Some herbs have been found to be safe, but others, even in small amounts, can be toxic, and the nurse
would not recommend the use of such a therapy to a client. If the client is taking prescription medications, the client should consult
with the healthcare provider regarding the use of herbs, because serious interactions may occur.
Test-Taking Strategy: Note the relationship between the subject, promoting sleep, and the correct option. Also note that the
incorrect options are comparable or alike in that they are invasive measures. Review complementary and alternative therapies that
will assist in promoting sleep.
Content Area: Complementary and Alternative Therapies
Giddens Concepts: Client Education, Sleep
HESI Concepts: Teaching and Learning/Patient Education, Comfort
89. 89.ID: 9477008717
A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain?
A. It has a prolonged presence
B. It is a result of injury Correct
C. It lasts longer than 6 months
D. It is usually the result of a chronic disorder

Rationale: Acute pain follows acute injury, disease, or surgical intervention and is rapid in onset and variable in intensity (mild to
severe). It lasts a brief time, usually less than 6 months. The incorrect options are descriptions of chronic pain.
Test-Taking Strategy: Focus on the subject, acute pain. Note that the incorrect options are comparable or alike in that they suggest
a long-term problem. Review the characteristics of acute and chronic pain
Content Area: Vital Signs
Giddens Concepts: Caregiving, Pain
HESI Concepts: Caregiving, Comfort-Pain
90. 90.ID: 9477006339
The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain?
A. A client with osteoarthritis Correct
B. A client with angina pectoris
C. A client who has undergone appendectomy
D. A client with a leg fracture who is in skeletal traction

Rationale: Chronic pain is associated with chronic disease. The pain is prolonged, varies in intensity, and lasts longer than 6 months.
The incorrect options are clients who are likely to experience acute pain.
Test-Taking Strategy: Focus on the subject, chronic pain. Think about the word “chronic and note that the correct option is the only
one that identifies a chronic problem. Review the characteristics of acute and chronic pain
Content Area: Vital Signs
Giddens Concepts: Care Coordination, Pain
HESI Concepts: Care Coordination, Comfort-Pain
Louis: Saunders.
91. 91.ID: 9477010177
A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for
pain. Which priority intervention does the nurse include in the plan?
A. Encouraging oral fluid intake
B. Maintaining the client in a supine position
C. Encouraging coughing and deep breathing Correct
D. Administering the morphine sulfate around the clock

Rationale: Morphine sulfate can depress respiration and suppress the cough reflex, putting the postoperative client at greater risk
for atelectasis and subsequent pneumonia. The client should be encouraged to cough and deep-breathe to prevent these
postoperative complications. Keeping the client supine is counterproductive and could lead to atelectasis. Adequate fluid intake
helps liquefy secretions, making their expulsion easier, but does not prevent atelectasis unless coughing and deep breathing is also
performed. Because the medication is prescribed as needed, it would not be administered around the clock.
Test-Taking Strategy: Note the strategic word “priority.” Also note that the client has just undergone surgery and is receiving
morphine sulfate. Use the ABCs — airway, breathing, and circulation — to find the correct option. Review nursing considerations
related to the use of morphine sulfate
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation/Gas Exchange, Safety
92. 92.ID: 9477002382
A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the
client while the clientis receiving this medication? Select all that apply.
A. Polyuria
B. Diarrhea
C. Tachycardia Correct
D. Hypotension Correct
E. Mental clouding Correct

Rationale: Side/adverse effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia,
drowsiness and mental clouding, constipation, and urine retention. The incorrect options are effects opposite those expected with
meperidine hydrochloride.
Test-Taking Strategy: Focus on the subject, side/adverse effects. Recalling the medication classification of meperidine
hydrochloride and thinking about the effects of opioid analgesics will help direct you to the correct options. Review the
side/adverse effects of meperidine hydrochloride
Giddens Concepts: Gas Exchange, Safety
HESI Concepts: Oxygenation/Gas Exchange, Safety
Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 783). St. Louis: Mosby.
93. 93.ID: 9477003518
Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking
this medication? Select all that apply.
A. Volume of urine output Correct
B. Strength of peripheral pulses
C. Ability to move the extremities
D. Frequency of bowel movements Correct
E. Color, motion, and sensation of extremities Incorrect

Rationale: Because urine retention may occur with the use of opioid analgesics, the nurse would monitor the volume of the client’s
urine output. Because the client is also at risk for constipation, the nurse would monitor the frequency of bowel movements. Other
side/adverse effects include hypotension and slowed respiration. The incorrect options are not specifically associated with this
medication.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they involve assessment of the extremities. Also
recall that codeine sulfate can cause urine retention and constipation. Review nursing measures related to the administration of
codeine sulfate.
Giddens Concepts: Clinical Judgment, Pain
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Pain
94. 94.ID: 9477008707
A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery.
The nurse responds by telling the client that in this technique, the clientwill experience which?
A. Become totally unaware of pain
B. Ignore the pain by focusing on the alternate activity
C. Alter pain perception though the influence of positive suggestion
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
Content Area: Complementary and Alternative Therapies
Giddens Concepts: Coping, Pain
HESI Concepts: Stress and Coping, Pain
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?
A. Reduces muscle tension
B. Dilates the blood vessels
C. Promotes muscle relaxation
D. Reduces blood flow to the extremity Correct

Rationale: The application of cold reduces blood flow through its vasoconstriction action and eases localized pain. Cold also reduces
the oxygen need of the tissues and promotes blood coagulation at the site of injury. The incorrect options are the effects of heat
application.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that they are effects of heat application. Also, recall the
effects of heat and cold on the blood vessels; this will help you eliminate the option that states that cold packs dilate the blood
vessels. Review the effects of heat and cold application
Giddens Concepts: Perfusion, Pain
HESI Concepts: Perfusion, Pain - Comfort
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 986-987). St. Louis: Mosby.
96. 96.ID: 9476999134
A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the
application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is
extremely edematous. The nurse should take which action?
A. Apply the cold compress to the ankle
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
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Perfusion
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. “I shouldn’t lie on the pad.”
B. “I’ll avoid using the high setting.”
C. “I can pin the pad around the affected area.” Correct
D. “I’ll need to keep an eye on my skin for redness.”

Rationale: One conventional form of heat therapy is the electric heating pad. The nurse instructs the client to avoid using the pad on
the high setting and to never lie on the pad, because these actions can result in burns. The client is also instructed not to insert a
safety pin through the pad, which could result in an electric shock. The client must check the skin frequently for redness.
select the incorrect client statement. Think about the dangers associated with the use of a heating pad and the risks associated with
burns. This will direct you to the correct option. Review client teaching points for the use of a heating pad
98. 98.ID: 9477012994
Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application?
A. An older client Correct
B. A client with renal calculi
C. A client with osteoporosis
D. A client with rheumatoid arthritis

Rationale: Older clients have diminished sensitivity to pain and are therefore at great risk for injury from heat or cold applications.
Other clients at risk for injury are the very young; those with open wounds; those with spinal cord injuries or peripheral vascular
disorders, such as the client with diabetes mellitus; and those who are confused or unconscious.
Test-Taking Strategy: Focus on the subject, the client at greatest risk for injury from a heat ot cold application. Recalling the sensory
changes that occur in the older client will direct you to the correct option. Review the clients at risk for injury from heat or cold
applications
Giddens Concepts: Safety, Tissue Integrity
HESI Concepts: Safety, Tissue Integrity
Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., pp. 985, 989). St. Louis: Mosby.
99. 99.ID: 9477008771
A client about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-
controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. Which information should the nurse provide to
the client?
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
Giddens Concepts: Client Education, Pain
HESI Concepts: Teaching and Learning/Patient Education, Pain-Comfort
100. 100.ID: 9477010185
Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply.
A. A client who has undergone colectomy Correct
B. A client with acute pancreatitis Correct
C. A client who has undergone gastrectomy Correct
D. A client with renal insufficiency
E. A client with Alzheimer’s disease

Rationale: A PCA pump contains a cartridge or syringe that holds the prescribed pain medication. The client pushes a button to
administer a dose of the medication within limitations prescribed by the health care provider. The client must be able to understand
the use of the equipment and be physically able to locate and press the button to deliver the dose. Clients who are confused and
unresponsive, those with neurological disease, and those with impaired renal or pulmonary functions are not candidates for PCA.
Test-Taking Strategy: Focus on the subject, clients who can use a PCA pump. Recalling that a PCA pump allows the client to push a
button and administer a dose of medication will direct you to the correct options. Review the appropriate uses of a PCA pump
Giddens Concepts: Pain, Safety
HESI Concepts: Pain-Comfort, Safety

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Module 7 Exam

A. Spaghetti with fresh tomatoes Correct

B. Boiled lobster with baked potato

C. Grilled chicken with turnip greens Correct

D. Instant hot cereal with bacon

E. Tomato soup with a ham sandwich Incorrect

E. Chicken liver Correct

B. Apple juice Correct

C. Orange juice Incorrect

D. Chicken broth Correct

E. Orange gelatin Correct

F. Vanilla ice cream

B. High in fiber Correct

C. Low in residue Incorrect

C. Green olives Incorrect

D. Baked potato Correct

E. Fresh cherries Correct

A. Spare ribs, rice, gelatin, tea

B. Pasta, garlic bread, ginger ale

C. Chicken breast, broccoli, strawberries, milk Correct

D. Peanut butter and jelly sandwich, chocolate cake, tea

A. Lying down after eating Correct

B. Eating high-protein foods Correct

C. Drinking liquids with meals

D. Eating six small meals per day Correct

E. Eating concentrated sweets during the day

A. Chicken, potatoes, and cranberries

B. Spinach salad, milk, and a banana Correct

C. Peanut butter sandwich, milk, and prunes

D. Linguini with shrimp, tossed salad, and a plum Incorrect

C. Right heel Correct

D. Back of the head

C. Cooked custard Correct

A. Smoked ham, fresh carrots, boiled potato Incorrect

B. Hot dog in a bun, sauerkraut, baked beans

D. Shrimp, baked potato, salad with blue cheese dressing

F. Cereal with raisins

E. Orange juice Incorrect

A. Coffee, cola, and chocolate Correct

B. Oysters, lobster, and shrimp

C. Apples, oranges, and pineapple

D. Cottage cheese, cream cheese, and dairy creamers

B. Vitamin B12 Correct

A. One low in protein Correct

B. One high in fluids

C. One high in carbohydrates

D. One with a moderate amount of fat

A. Roast turkey with a baked potato Correct

B. Fruit plate with fresh whipped cream

C. Fried chicken with macaroni and cheese

D. Barbecued spare ribs with buttered noodles

C. Boiled potatoes Correct

D. Coffee with cream

F. Cranberry juice Correct

D. Low-fat cheese Incorrect

A. Not eating ice cream for 2 days

B. Omitting 8 oz (240 ml) of skim milk from that meal Correct

C. Omitting salad dressing and butter at lunchtime