a nurse cares for a client who is recovering from a closed percutaneous kidney biopsy the client states my pain has suddenly increased from a 3 to a 1
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Nursing Elites

HESI RN

HESI RN Medical Surgical Practice Exam

1. A client is recovering from a closed percutaneous kidney biopsy and reports increased pain from 3 to 10 on a scale of 0 to 10. Which action should the nurse take first?

Correct answer: C

Rationale: An abrupt increase in pain following a percutaneous kidney biopsy may indicate internal hemorrhage. Assessing the client's pulse rate and blood pressure is crucial as changes in vital signs can be indicative of hemorrhage. This assessment is essential in determining the client's hemodynamic status and the need for immediate intervention. Repositioning the client, administering pain medication, or checking urine color are not the priority actions in this situation and may delay necessary interventions for potential hemorrhage.

2. The client with chronic renal failure who is on a low-sodium diet should avoid which of the following foods?

Correct answer: B

Rationale: Canned soups are high in sodium, which can lead to fluid retention and hypertension in clients with chronic renal failure who are on a low-sodium diet. Fresh fruits, lean meats, and whole grain bread are generally lower in sodium and can be included in a low-sodium diet. Lean meats provide essential protein, fresh fruits offer vitamins and minerals, and whole grain bread provides fiber, making them suitable choices for individuals with chronic renal failure.

3. What information will the nurse provide when counseling a patient starting a sulfonamide drug for a urinary tract infection?

Correct answer: A

Rationale: The correct answer is A: Drink several quarts of water daily. This advice aims to prevent crystalluria, a potential side effect of sulfonamide drugs. Option B is incorrect because antacids should not be taken with sulfonamides as they can decrease drug absorption. Option C is incorrect as sulfonamides can increase sensitivity to sunlight, not requiring sun exposure limitations but sun protection measures. Option D is incorrect because a sore throat could indicate a more serious adverse effect and should be promptly reported for evaluation.

4. Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?

Correct answer: D

Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.

5. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

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