HESI RN
HESI RN Medical Surgical Practice Exam
1. A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the healthcare provider? (Select all that apply.)
- A. Foul-smelling drainage
- B. Bloody drainage at site
- C. A & B
- D. All of the above
Correct answer: C
Rationale: After a nephrostomy, the nurse should assess the client for complications and urgently notify the provider if there is foul-smelling drainage, bloody drainage at the site, or both. Foul-smelling drainage can indicate infection, while bloody drainage may suggest bleeding. Clear drainage is generally normal after a nephrostomy. A headache would not typically be directly related to nephrostomy complications. Therefore, options A and B are correct choices for urgent notification, making option C the correct answer.
2. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)
- A. Starting and stopping the urine stream involves using pelvic muscles.
- B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
- C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
- D. A & B
Correct answer: D
Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.
3. The nurse is caring for a patient who is ordered to receive PO trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 QID to treat a urinary tract infection caused by E. coli. The nurse will contact the provider to clarify the correct
- A. dose.
- B. drug.
- C. frequency.
- D. route.
Correct answer: C
Rationale: The correct answer is 'frequency.' Trimethoprim-sulfamethoxazole (TMP-SMX) is typically prescribed to be taken twice daily, not four times a day (QID). The dose, drug, and route are already specified in the order, so the nurse should contact the provider to clarify the frequency of administration to ensure optimal treatment for the urinary tract infection caused by E. coli. Choosing 'dose' is incorrect because the dose of 160/800 is already provided in the order. 'Drug' is incorrect because the medication Trimethoprim-sulfamethoxazole (TMP-SMX) is explicitly stated in the prescription. 'Route' is incorrect as PO (by mouth) is also clearly indicated in the prescription.
4. When working with a large population of African-American clients at a community health center, which priority assessment should a nurse include?
- A. Measure height and weight.
- B. Assess blood pressure.
- C. Observe for any signs of abuse.
- D. Ask about medications.
Correct answer: B
Rationale: Assessing blood pressure is the priority assessment when working with a population of African-American clients due to the high prevalence of hypertension in this group. African Americans have a higher risk of hypertension, which can lead to complications like end-stage renal disease. Monitoring blood pressure allows for the early detection and management of hypertension. While measuring height and weight, observing for signs of abuse, and asking about medications are important assessments, assessing blood pressure is crucial in this context to address the specific health needs of African-American clients.
5. A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?
- A. Pupil constriction
- B. Increased urine output
- C. Complaints of dry mouth
- D. Complaints of feeling sweaty
Correct answer: D
Rationale: The correct answer is D: 'Complaints of feeling sweaty.' Scopolamine, an anticholinergic medication, commonly causes the side effect of decreased sweating, not increased urine output or pupil constriction. While dry mouth is a possible side effect, it is less likely than the altered sweating pattern. Therefore, the nurse should monitor the client for complaints of feeling sweaty due to the potential side effect of decreased sweating associated with scopolamine.
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