HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?
- A. Eat high-protein foods to achieve ideal body weight
- B. Drink at least 8 cups (1920mL) of water per day
- C. Use an electric heating pad when pain is at its worst
- D. Encourage active range of motion to prevent stiffness
Correct answer: B
Rationale: The correct answer is to instruct the client to drink at least 8 cups (1920mL) of water per day. Adequate hydration helps to prevent the formation of uric acid crystals, which can exacerbate gout symptoms. Choice A is incorrect because while maintaining a healthy weight is important, it doesn't directly address gout management. Choice C is incorrect because using an electric heating pad can worsen inflammation. Choice D is incorrect because active range of motion may exacerbate pain and inflammation in the affected joints.
2. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
- A. Competent venous valves.
- B. Decreased blood volume.
- C. Increase in muscular activity.
- D. Increased venous pressure.
Correct answer: D
Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PVD), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema. Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema. Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume. Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.
3. To assess the quality of an adult client's pain, what approach should the nurse use?
- A. Observe body language and movement.
- B. Ask the client to describe the pain.
- C. Identify effective pain relief measures.
- D. Provide a numeric pain scale.
Correct answer: B
Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.
4. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Monitoring catheter drainage
- B. Decreasing the flow rate
- C. Irrigating the catheter manually
- D. Discontinuing infusing the solution
Correct answer: C
Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.
5. What do crackles heard on lung auscultation indicate?
- A. Cyanosis.
- B. Bronchospasm.
- C. Airway narrowing.
- D. Fluid-filled alveoli.
Correct answer: D
Rationale: Crackles heard on lung auscultation are caused by the popping open of small airways that are filled with fluid. This is commonly associated with conditions such as pulmonary edema, pneumonia, or heart failure. Cyanosis (Choice A) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, not directly related to crackles. Bronchospasm (Choice B) refers to the constriction of the airway smooth muscle, causing difficulty in breathing but does not typically produce crackles. Airway narrowing (Choice C) can lead to wheezing but is not directly linked to crackles heard on auscultation.
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