HESI RN
HESI Medical Surgical Assignment Exam
1. After educating a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
- A. I can prevent more damage to my kidneys by managing my blood pressure.
- B. If I have increased urination at night, I need to drink less fluid during the day.
- C. I need to see the registered dietitian to discuss limiting my protein intake.
- D. It is important that I take my antihypertensive medications as directed.
Correct answer: B
Rationale: Choice B is incorrect because the client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and they should be thoroughly assessed for potential dehydration. To decrease increased nocturnal voiding, clients should consume fluids earlier in the day. Choices A, C, and D are correct statements. Managing blood pressure is crucial to slow the progression of renal dysfunction. Limiting protein intake is important in renal disease management, and clients should be referred to a dietitian as needed. Taking antihypertensive medications as directed is essential for blood pressure control.
2. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:
- A. The tube is patent
- B. There is probably a kink in the tubing
- C. Suction should be added to the system
- D. The client is retaining airway secretions
Correct answer: A
Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.
3. The patient is beginning furosemide and has started a 2-week course of a steroid medication. What should the nurse recommend?
- A. Avoid consuming licorice to prevent excess potassium loss.
- B. Report a urine output less than 600 mL/24 hours.
- C. Obtain an order for a potassium supplement.
- D. Take the furosemide in the morning.
Correct answer: C
Rationale: When a patient is taking furosemide and a steroid medication, there is an increased risk of potassium loss due to the interaction between the two drugs. Consuming licorice should be avoided as it can worsen potassium loss. Reporting a urine output less than 600 mL/24 hours is not directly related to the drug interaction and may not be necessary. Taking furosemide at bedtime is not the primary concern when a patient is concurrently on a steroid medication and furosemide. Therefore, obtaining an order for a potassium supplement is the most appropriate recommendation to counteract the potential potassium loss.
4. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action indicates the UAP needs additional teaching?
- A. Toileting the client after breakfast
- B. Changing the client’s incontinence brief when wet
- C. Encouraging the client to drink fluids
- D. Recording the client’s incontinence episodes
Correct answer: B
Rationale: The correct action that indicates the UAP needs additional teaching is choice B, 'Changing the client’s incontinence brief when wet.' Habit training is a technique used to manage incontinence, and it is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training, which involves scheduled toileting and promoting bladder control. Choices A, C, and D are appropriate actions that support the client’s care: toileting the client after meals, encouraging fluid intake, and documenting incontinence episodes are all important aspects of managing incontinence and monitoring the client's condition.
5. A patient is admitted to the hospital for treatment of pneumonia after complaining of high fever and shortness of breath. The patient was not able to produce sputum for a culture. The nurse will expect the patient’s provider to order
- A. a broad-spectrum antibiotic.
- B. a narrow-spectrum antibiotic.
- C. multiple antibiotics.
- D. the pneumococcal vaccine.
Correct answer: A
Rationale: In this scenario where the offending organism causing pneumonia is unknown due to the inability to produce sputum for culture, the appropriate choice is a broad-spectrum antibiotic. Broad-spectrum antibiotics are effective against a wide range of bacteria and are commonly used when the specific pathogen is unidentified. Narrow-spectrum antibiotics target specific types of bacteria and are chosen based on culture and sensitivity results. Using multiple antibiotics without a clear indication from culture and sensitivity testing can lead to antibiotic resistance and is not recommended in this situation. Additionally, the pneumococcal vaccine is preventive and does not treat an ongoing infection like pneumonia.
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