HESI RN
RN Medical/Surgical NGN HESI 2023
1. A nurse obtains a sterile urine specimen from a client’s Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next?
- A. Clamp another section of the tube to create a fixed sample section for retrieval.
- B. Insert a syringe into the injection port and aspirate the quantity of urine required.
- C. Clean the injection port cap of the drainage tubing with a povidone-iodine solution.
- D. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.
Correct answer: C
Rationale: The correct next action for the nurse to take after applying a clamp to the drainage tubing distal to the injection port is to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic like povidone-iodine solution or alcohol. This step is crucial to prevent surface contamination before taking the urine sample. Clamping another section of the tube to create a fixed sample section or withdrawing and discarding urine are unnecessary and could lead to potential contamination. Inserting a syringe into the injection port and aspirating the required amount of urine directly from the catheter is the correct method for obtaining the urine sample, but cleaning the injection port cap should precede this step to ensure sterility.
2. A client with gastroesophageal reflux disease (GERD) reports frequent heartburn. What dietary modification should the nurse recommend?
- A. Avoid eating large meals late at night.
- B. Eat a high-fat diet to buffer stomach acid.
- C. Reduce fluid intake to prevent acid reflux.
- D. Consume spicy foods to neutralize stomach acid.
Correct answer: A
Rationale: The correct answer is to recommend avoiding eating large meals late at night. This dietary modification can help reduce the risk of acid reflux, which can exacerbate GERD symptoms. Consuming smaller, more frequent meals is generally recommended to minimize pressure on the lower esophageal sphincter. Choice B is incorrect because a high-fat diet can worsen GERD symptoms by delaying stomach emptying. Choice C is incorrect because reducing fluid intake can lead to dehydration and will not prevent acid reflux. Choice D is incorrect because spicy foods can actually trigger or worsen acid reflux symptoms in individuals with GERD.
3. The client with chronic renal failure is being educated about the importance of a low-sodium diet. Which of the following statements by the client indicates a need for further teaching?
- A. I can eat canned vegetables as long as I rinse them first.
- B. I can use table salt sparingly.
- C. I can eat frozen dinners if they are labeled low-sodium.
- D. I can eat whatever I want as long as I avoid salty foods.
Correct answer: B
Rationale: The correct answer is B. Clients with chronic renal failure need to strictly limit their sodium intake. Advising the client to use table salt sparingly is incorrect as they should avoid table salt altogether to adhere to a low-sodium diet. Choice A is correct as rinsing canned vegetables can help reduce their sodium content. Choice C is correct as consuming frozen dinners labeled low-sodium can be a suitable option. Choice D is incorrect as it implies that avoiding only salty foods is sufficient, when in fact, overall sodium intake needs to be monitored closely.
4. The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?
- A. Reassure the client that sedation will subside with continued use
- B. Instruct the client to take the medication at bedtime
- C. Teach the client to take the medication with food
- D. Consult the healthcare provider to reduce the dosage
Correct answer: B
Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.
5. A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?
- A. Use sugar-free gum if you experience a metallic taste in your mouth.
- B. Drink fluids at mealtime to prevent early satiety.
- C. Foods that are higher in fat can help nausea.
- D. Raw fruits and vegetables will be easier for your body to digest.
Correct answer: A
Rationale: The correct answer is A. Using sugar-free gum can help alleviate the metallic taste often experienced during chemotherapy treatments. Choices B, C, and D are incorrect. Drinking fluids at mealtime may worsen early satiety, foods higher in fat can exacerbate nausea, and raw fruits and vegetables may be harder for the body to digest and may pose a risk of infection for individuals with compromised immune systems.