HESI RN
HESI Medical Surgical Practice Quiz
1. A client with overflow incontinence needs assistance with elimination. What intervention should the nurse include in the plan of care?
- A. Stroke the medial aspect of the thigh.
- B. Use intermittent catheterization.
- C. Provide digital anal stimulation.
- D. Use the Valsalva maneuver.
Correct answer: D
Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.
2. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?
- A. Fluid volume deficit (FVD)
- B. Fluid volume excess (FVE)
- C. Mild extracellular fluid (ECF) deficit
- D. Renal failure
Correct answer: A
Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).
3. A client who underwent surgery and experienced significant blood loss is being cared for by a nurse. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.)
- A. Urine output of 100 mL in 4 hours
- B. Large amount of sediment in the urine
- C. A & B
- D. Amber, odorless urine
Correct answer: C
Rationale: The nurse must monitor for signs of acute kidney injury in a postoperative client who had major blood loss. Low urine output, presence of sediment in the urine, and low blood pressure should raise concerns and be reported to the healthcare provider promptly. Postoperatively, assessing urine characteristics is crucial. Sediment, hematuria, and urine output less than 0.5 mL/kg/hour for 3 to 4 hours should be reported. While a urine output of 100 mL in 4 hours is low, it should be compared to the recommended 0.5 mL/kg/hour over a longer period. Perfusion to the kidneys is a priority, hence the importance of addressing low blood pressure. Amber, odorless urine is considered normal and does not indicate an immediate concern for acute kidney injury, unlike low urine output and presence of sediment.
4. A healthcare professional is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted as the most specific indicator of this disease?
- A. Hemoglobin
- B. Serum bilirubin
- C. Blood urea nitrogen (BUN)
- D. Erythrocyte sedimentation rate (ESR)
Correct answer: B
Rationale: Serum bilirubin is the most specific indicator of hepatitis as it reflects liver dysfunction. Hemoglobin, blood urea nitrogen (BUN), and erythrocyte sedimentation rate (ESR) are not specific to hepatitis. Hemoglobin measures the oxygen-carrying capacity of red blood cells, BUN evaluates kidney function, and ESR is a nonspecific marker of inflammation or infection.
5. The client with chronic kidney disease (CKD) is being taught about the necessary sodium restriction in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed?
- A. I am thrilled that I can continue to eat fast food.
- B. I will cut out bacon with my eggs every morning.
- C. My cooking style will change by not adding salt.
- D. I will probably lose weight by cutting out potato chips.
Correct answer: A
Rationale: Choice A, 'I am thrilled that I can continue to eat fast food,' indicates a lack of understanding as fast food is typically high in sodium, which is detrimental for individuals with CKD. The client should be advised to avoid fast food due to its high sodium content. Choices B, C, and D demonstrate a good understanding of the need for sodium restriction in the diet to prevent complications associated with CKD. Cutting out bacon, avoiding salt in cooking, and eliminating high-sodium snacks like potato chips are all positive steps towards managing CKD.
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