a client is being discharged following a cystectomy and urinary diversion what is the most important instruction for the nurse to provide
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Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. A client is being discharged following a cystectomy and urinary diversion. What is the most important instruction for the nurse to provide?

Correct answer: B

Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.

2. An older client with a long history of coronary artery disease, HTN, and HF arrives in the ED in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?

Correct answer: D

Rationale: The correct answer is D: Reduced preload. Furosemide is a diuretic that reduces fluid overload in heart failure, which lowers the preload (the volume of blood in the ventricles before contraction). By reducing this volume, furosemide improves symptoms of heart failure. While furosemide may lead to increased urine output and lower blood pressure, these effects are secondary to the reduction in preload. Decreased heart rate is not a direct effect of furosemide in heart failure.

3. A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?

Correct answer: C

Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.

4. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

5. A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.

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