HESI RN Medical Surgical Nursing

Question 1 of 5

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

A. Encourage deep breathing and coughing exercises.B. Teach a family member to administer eye drops.C. Provide an eye shield to be worn while sleepingD. Obtain vital signs every 2 hours during hospitalization.

Correct Answer: C

Rationale: An eye shield is crucial to protect the operated eye from accidental injury during sleep, preventing rubbing and potential complications. Deep breathing and coughing can increase intraocular pressure, teaching medication administration is not an immediate priority, and frequent vital sign monitoring is excessive for cataract surgery.

Question 2 of 5

A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?

A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);

Correct Answer: C

Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.

Question 3 of 5

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A. Neutrophil count.B. C-reactive protein level.C. Platelet count.D. Serum potassium and sodium levels.

Correct Answer: B

Rationale: C-reactive protein (CRP) is a sensitive marker of inflammation, which often accompanies worsening wound size. Neutrophils indicate acute infection, platelets relate to clotting, and electrolytes are not directly related to wound healing.

Question 4 of 5

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A. Take the diuretic every day, regardless of weight loss or muscle weakness.B. Weigh yourself daily at the same time and report excessive weight loss.C. Limit fluid intake while taking the diuretic to reduce fluid retention.D. Stop taking the medication when the edema in the lower extremities subsides.

Correct Answer: B

Rationale: Daily weight monitoring helps evaluate diuretic effectiveness and detect complications. Continuous diuretic use despite weakness, limiting fluids, or stopping medication without consultation can lead to adverse outcomes.

Question 5 of 5

The nurse is evaluating a client's symptoms, and formulates the nursing problem, 'High risk for injury due to potential urinary tract infection.' Which symptoms indicate the need for this nursing problem?

A. Straining on urination and nocturiaB. Azotemia and anorexia.C. Hematuria and proteinuria.D. Fever and dysuria.

Correct Answer: D

Rationale: Fever and dysuria are classic UTI symptoms, indicating a risk for serious complications like pyelonephritis or sepsis. Other options suggest urinary issues but are less directly linked to injury risk.

HESI RN Medical Surgical Nursing | Nurselytic

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HESI RN

HESI RN