the nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection which statement by the patient indicates a ne
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Nursing Elites

HESI RN

HESI Medical Surgical Assignment Exam

1. The nurse is providing teaching to a patient who will begin taking a cephalosporin to treat an infection. Which statement by the patient indicates a need for further teaching?

Correct answer: A

Rationale: Patients should take all of an antibiotic regimen even after symptoms clear to ensure complete treatment of the infection.

2. 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.)

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.

3. A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the client’s fluid balance is stable at this time?

Correct answer: C

Rationale: The absence of adventitious sounds upon auscultation of the lungs is a key indicator that the client's fluid balance is stable. Adventitious sounds, such as crackles or wheezes, are typically heard in conditions of fluid overload, indicating that the body is retaining excess fluid. Choices A and B, decreased calcium levels and increased phosphorus levels, are common laboratory findings associated with chronic kidney disease (CKD) and are not directly related to fluid balance. Increased edema in the legs is a sign of fluid imbalance, suggesting fluid retention in the tissues, which would not indicate stable fluid balance in a client with CKD on fluid restrictions.

4. Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?

Correct answer: B

Rationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL for females. A uric acid level of 5.8 mg/dL falls within the normal range. Choices A, C, and D are outside the normal reference range, making them incorrect. Choice B is the correct answer as it aligns with the typical uric acid levels in the blood.

5. A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement?

Correct answer: B

Rationale: Obtaining a urethral drainage specimen for culture is crucial in diagnosing a potential sexually transmitted infection (STI) in this client. While assessing for perineal symptoms like itching, erythema, and excoriation (Choice C) may provide additional information, obtaining a culture is more definitive. Observing for a chancroid-like lesion (Choice A) is not as pertinent as obtaining a culture for a broader diagnostic approach. Identifying all sexual partners in the last four days (Choice D) is important for contact tracing but obtaining a specimen for culture takes priority in this scenario.

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