HESI RN
RN Medical/Surgical NGN HESI 2023
1. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)
- A. Urge incontinence involves a post-void residual volume less than 50 mL.
- B. Stress incontinence occurs due to weak pelvic floor muscles.
- C. Stress incontinence usually occurs in people with dementia.
- D. Urge incontinence can be managed by increasing fluid intake.
Correct answer: B
Rationale: The correct statement to include in the education about urge incontinence and stress incontinence is choice B. Stress incontinence occurs due to weak pelvic floor muscles or urethral sphincter, leading to the inability to tighten the urethra sufficiently to overcome increased detrusor pressure. This condition is common after childbirth when pelvic muscles are stretched and weakened. Urge incontinence, on the other hand, is characterized by the inability to suppress the contraction signal from the detrusor muscle. It is often associated with abnormal detrusor contractions, which can be due to neurological abnormalities rather than post-void residual volume. Choice A is incorrect because urge incontinence is not defined by post-void residual volume. Choice C is incorrect as stress incontinence is not usually linked to dementia. Choice D is incorrect because increasing fluid intake is not a management strategy for urge incontinence.
2. The nurse is caring for a patient who is ordered to receive PO trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 QID to treat a urinary tract infection caused by E. coli. The nurse will contact the provider to clarify the correct
- A. dose.
- B. drug.
- C. frequency.
- D. route.
Correct answer: C
Rationale: The correct answer is 'frequency.' Trimethoprim-sulfamethoxazole (TMP-SMX) is typically prescribed to be taken twice daily, not four times a day (QID). The dose, drug, and route are already specified in the order, so the nurse should contact the provider to clarify the frequency of administration to ensure optimal treatment for the urinary tract infection caused by E. coli. Choosing 'dose' is incorrect because the dose of 160/800 is already provided in the order. 'Drug' is incorrect because the medication Trimethoprim-sulfamethoxazole (TMP-SMX) is explicitly stated in the prescription. 'Route' is incorrect as PO (by mouth) is also clearly indicated in the prescription.
3. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?
- A. Implement behavior modification therapy.
- B. Initiate caloric and nutritional therapy.
- C. Evaluate the client for low self-esteem.
- D. Record daily weights and graph trends.
Correct answer: B
Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.
4. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness episodes
Correct answer: D
Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.
5. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?
- A. Administer a diuretic as prescribed
- B. Restrict the child’s fluid intake
- C. Notify the healthcare provider
- D. Measure the child’s abdominal girth
Correct answer: C
Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.