a nurse cares for a client who is having trouble voiding the client states i cannot urinate in public places how should the nurse respond
Logo

Nursing Elites

HESI RN

Evolve HESI Medical Surgical Practice Exam

1. A client expresses difficulty voiding in public places. How should the nurse respond?

Correct answer: D

Rationale: The nurse should prioritize the client's privacy when addressing issues related to voiding discomfort in public places. Closing the curtain in the current room would offer immediate privacy and support the client's needs. Turning on the faucet is not an evidence-based intervention for voiding difficulties. Prescribing a diuretic is not appropriate without further assessment. While moving to a room with a private bathroom might be ideal, it may not be immediately feasible, making ensuring privacy in the current setting the most appropriate action.

2. In a patient with liver cirrhosis, which of the following lab results would be expected?

Correct answer: A

Rationale: In a patient with liver cirrhosis, increased bilirubin levels would be expected. Liver cirrhosis leads to impaired liver function, causing a decrease in the liver's ability to process bilirubin, leading to its accumulation in the blood. This results in elevated bilirubin levels. Decreased albumin levels (choice B) may occur in liver cirrhosis due to impaired liver synthesis of proteins, but it is not as specific as increased bilirubin levels. Increased liver enzymes (choice C) can be seen in liver damage but are not as characteristic as elevated bilirubin levels. Decreased platelet count (choice D) can occur in liver cirrhosis due to hypersplenism, but it is not as specific as increased bilirubin levels in this context.

3. Which of the following is a primary intervention for a patient with sepsis?

Correct answer: D

Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.

4. A client receiving warfarin (Coumadin) therapy should have which of the following laboratory results reviewed to evaluate the effectiveness of the therapy?

Correct answer: C

Rationale: The correct answer is C: International normalized ratio (INR). The INR is the most appropriate laboratory result to review when evaluating the effectiveness of warfarin (Coumadin) therapy. Warfarin is an anticoagulant medication, and the INR helps determine if the dosage is within a therapeutic range to prevent clotting or bleeding complications. Choice A, a Complete Blood Count (CBC), provides information about the cellular components of blood but does not directly assess the anticoagulant effects of warfarin. Choice B, Prothrombin time (PT), measures the time it takes for blood to clot but is not as specific for monitoring warfarin therapy as the INR. Choice D, Partial Thromboplastin Time (PTT), evaluates the intrinsic pathway of coagulation and is not the primary test used to monitor warfarin therapy.

5. When giving a report about a client who had a gastrectomy from the intensive care unit to the post-surgical unit nurse, what is the most effective way to assure essential information is reported?

Correct answer: C

Rationale: Using a printed checklist with individualized information is the most effective way to ensure that all key details about the client who had a gastrectomy are covered during the report. This method helps in structuring the information systematically, reducing the risk of missing important details. Face-to-face communication in a quiet room (Choice A) is important for effective communication but may not guarantee the coverage of all essential information. Audiotaping the report (Choice B) may not be practical for immediate reference or interaction. Documenting in the electronic health record (Choice D) is essential but may not facilitate a comprehensive real-time exchange of information between the nurses.

Similar Questions

The nurse is caring for a patient who will receive 10% calcium gluconate to treat a serum potassium level of 5.9 mEq/L. The nurse performs a drug history prior to beginning the infusion. Which drug taken by the patient would cause concern?
A client's urinalysis results show a urine osmolality of 1200 mOsm/L. What action should the nurse take?
A client with Diabetes Insipidus (DI) is being cared for by a nurse. Which data warrants the most immediate intervention by the nurse?
When preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?
A client with acute kidney injury (AKI) weighing 50kg and having a potassium level of 6.7mEq/L (6.7mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first?

Access More Features

HESI RN Basic
$69.99/ 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