a client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct which finding is most important for the nurse to rep
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Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam

1. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: A

Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.

2. The nurse is caring for a patient whose serum sodium level is 140 mEq/L and serum potassium level is 5.4 mEq/L. The nurse will contact the patient’s provider to discuss an order for

Correct answer: A

Rationale: In the scenario presented, the patient is experiencing mild hyperkalemia with a potassium level of 5.4 mEq/L. The appropriate intervention for mild hyperkalemia is a low-potassium diet to restrict potassium intake. This helps in managing and preventing further elevation of potassium levels. Intravenous sodium bicarbonate is not indicated as the patient's sodium level is normal at 140 mEq/L. Kayexalate, a cation-exchange resin, is typically used for severe hyperkalemia to promote potassium excretion. Salt substitutes, which often contain potassium chloride, should be avoided in patients with hyperkalemia as they can exacerbate the condition by increasing potassium levels further.

3. The client with chronic renal failure is being taught about the importance of fluid restrictions. Which of the following statements by the client indicates that the teaching has been effective?

Correct answer: B

Rationale: The correct answer is B: 'I will need to limit my fluid intake to prevent fluid overload.' In chronic renal failure, fluid restrictions are crucial to prevent fluid overload and further damage to the kidneys. Option A is incorrect as unrestricted fluid intake can worsen the condition. Option C is also incorrect as total fluid intake needs to be restricted, not just other fluids. Option D is not ideal because thirst may not accurately reflect the body's fluid needs in chronic renal failure.

4. The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?

Correct answer: B

Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.

5. The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?

Correct answer: B

Rationale: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.

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