HESI RN
HESI RN Medical Surgical Practice Exam
1. A client is being taught about self-catheterization in the home setting. Which statements should the nurse include in this client’s teaching? (Select all that apply.)
- A. Wash your hands before and after self-catheterization.
- B. Use lubricant on the tip of the catheter before insertion.
- C. A & B
- D. Self-catheterize at least twice a day or every 12 hours.
Correct answer: C
Rationale: In teaching a client about self-catheterization, it is essential to emphasize proper hand hygiene before and after the procedure to prevent infections. Using lubricant on the catheter helps with insertion and reduces discomfort. Therefore, statements A and B are correct and should be included in the client's teaching. Option D is incorrect because self-catheterization frequency should be individualized based on the client's needs, and a specific time frame like every 12 hours may not be suitable for everyone. Choosing a smaller lumen catheter is preferred over a larger one. Self-catheterization should not be limited to a specific time frame but should be based on the individual's needs and voiding patterns. Therefore, option C is the correct choice as it includes the two essential statements for teaching self-catheterization in the home setting.
2. Which client should the nurse recognize as most likely to experience sleep apnea?
- A. Middle-aged female who takes a diuretic nightly.
- B. Obese older male client with a short, thick neck.
- C. Adolescent female with a history of tonsillectomy.
- D. School-aged male with a history of hyperactivity disorder.
Correct answer: B
Rationale: The correct answer is B. Sleep apnea is characterized by pauses in breathing during sleep, often due to a collapsed or blocked airway. Obesity and having a short, thick neck are risk factors for sleep apnea because excess fat around the neck can obstruct the airway. Option A (middle-aged female who takes a diuretic nightly) does not present as a common risk factor for sleep apnea. Option C (adolescent female with a history of tonsillectomy) may have had tonsils removed, which could reduce the risk of sleep apnea. Option D (school-aged male with a history of hyperactivity disorder) is not directly associated with an increased risk of sleep apnea.
3. The patient weighs 75 kg and is receiving IV fluids at a rate of 50 mL/hour, having consumed 100 mL orally in the past 24 hours. What action will the nurse take?
- A. Contact the provider to ask about increasing the IV rate to 90 mL/hour.
- B. Discuss with the provider the need to increase the IV rate to 150 mL/hour.
- C. Encourage the patient to drink more water so the IV can be discontinued.
- D. Instruct the patient to drink 250 mL of water every 8 hours.
Correct answer: A
Rationale: The recommended daily fluid intake for adults is 30 to 40 mL/kg/day. For a patient weighing 75 kg, the minimum intake should be 2250 mL/day. The patient is currently receiving 1200 mL IV and 100 mL orally, totaling 1300 mL. Increasing the IV rate to 90 mL/hour would provide a total of 2160 mL, which could meet the patient's needs if oral intake continues. Option B suggests increasing the IV rate to 150 mL/hour, resulting in an excessive fluid intake of 3600 mL/day, surpassing the recommended amount. Option C, encouraging increased fluid intake, is not recommended as the patient is already struggling with fluid intake. Option D, instructing the patient to drink 250 mL of water every 8 hours, would still fall short of the required fluid intake of 2250 mL/day.
4. A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?
- A. A 78-year-old female who is confused
- B. A 65-year-old male with diabetes mellitus
- C. A 52-year-old female with kidney failure
- D. A 47-year-old male with arthritis
Correct answer: A
Rationale: For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from other types of bladder training. A confused client may need structured assistance to establish a regular bathroom routine, which can help manage urge incontinence effectively. Clients with diabetes mellitus, kidney failure, or arthritis may require different strategies tailored to their specific conditions.
5. What is a key intervention for a patient with diabetic ketoacidosis (DKA)?
- A. Administering insulin
- B. Administering IV fluids
- C. Administering oral glucose
- D. Administering oral fluids
Correct answer: A
Rationale: Administering insulin is a crucial intervention for a patient with diabetic ketoacidosis (DKA) because it helps in managing hyperglycemia and ketosis by promoting the uptake of glucose by cells and inhibiting the production of ketones. IV fluids are necessary to correct dehydration and electrolyte imbalances commonly seen in DKA but are not the primary treatment for the condition. Administering oral glucose would exacerbate hyperglycemia in a patient with DKA, while administering oral fluids alone would not effectively address the underlying metabolic disturbances seen in DKA.
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