a marathon runner comes into the clinic and states i have not urinated very much in the last few days the nurse notes a heart rate of 110 beatsmin and
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Quiz

1. A marathon runner comes into the clinic and states, 'I have not urinated very much in the last few days.' The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?

Correct answer: A

Rationale: The priority action for the nurse is to give the client a bottle of water immediately. The athlete's symptoms of decreased urination, along with a heart rate of 110 beats/min and low blood pressure of 86/58 mm Hg, indicate mild dehydration. Rehydration should begin promptly to address the dehydration. Teaching the client to drink 2 to 3 liters of water daily is a good long-term strategy but not the immediate priority. Starting an intravenous line for fluids may be necessary if oral hydration is insufficient or if the degree of dehydration is severe. Performing an electrocardiogram is not indicated at this time as the priority is addressing the dehydration.

2. The client has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?

Correct answer: D

Rationale: Assessing the dorsalis pedis pulse is crucial after a femoral-popliteal bypass surgery to determine adequate circulation distal to the surgical site. A strong dorsalis pedis pulse indicates sufficient blood flow to the foot, which is essential for monitoring postoperative status. The radial pulse (A) is not the most relevant assessment as it does not provide direct information on circulation in the lower extremities. The femoral pulse (B) may not accurately reflect circulation distal to the surgical site. The apical pulse (C) is used primarily to assess the heartbeat and cardiac function, not circulation in the lower extremities.

3. A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?

Correct answer: C

Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.

4. A client is starting urinary bladder training. Which statement should the nurse include in this client’s teaching?

Correct answer: B

Rationale: In urinary bladder training, the client should be taught to try to consciously hold their urine until the scheduled toileting time. This helps in training the bladder to hold urine for longer periods. Option A is incorrect because the goal is to consciously hold urine, not void immediately. Option C is incorrect as toileting at least every half hour may not promote bladder training. Option D is incorrect as increasing the toileting interval should be based on the client's comfort and progress, not just after being continent for a week.

5. The nurse is caring for several patients who are receiving antibiotics. Which order will the nurse question?

Correct answer: C

Rationale: The nurse should question the order for Erythromycin 300 mg IM QID. Erythromycin and other macrolides should not be given intramuscularly because they cause painful tissue irritation. Options A and B are correct routes for Azithromycin, either intravenously or orally. Option D is a correct route for Erythromycin, which is orally.

Similar Questions

The nurse is preparing to administer the first dose of intravenous ceftriaxone (Rocephin) to a patient. When reviewing the patient’s chart, the nurse notes that the patient previously experienced a rash when taking amoxicillin. What is the nurse’s next action?
An older female client has normal saline infusing at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?
A patient with a diagnosis of Cushing's syndrome is likely to exhibit which of the following symptoms?
A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?

Access More Features

HESI RN Basic
$89/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses