RN Medical Surgical HESI

Extract:

Question 1 of 5

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA), which information should the nurse include in the discharge instructions?

Correct Answer: B

Rationale: Monitoring urinary stream for decreased output detects complications like urinary retention post-TUNA, a priority for discharge teaching.

Question 2 of 5

The client is a 19-year-old male who sustained a closed skull fracture and a humerus fracture while skateboarding. A cast was applied to the right arm to stabilize the humerus, and the client will be admitted to monitor his neurological status. Specify which potential condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's response.

A. Increased intracranial pressure B. Spinal shock C. Hypovolemia D. Compartment syndrome E. Elevate the extremity F. Start a fluid bolus G. Draw a type and screen for a blood transfusion

Correct Answer: D

Rationale: Compartment syndrome is likely due to cast-related pressure. Elevate the extremity and remove the cast to relieve pressure. Monitor capillary refill and blood pressure for perfusion.

Question 3 of 5

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?

A. Return for periodic liver function studies. B. Massage joints to relax muscles and decrease pain. C. Limit use of mobility equipment to avoid muscle atrophy. D. Substitute natural fruit juices for carbonated drinks.

Correct Answer: A

Rationale: Colchicine and indomethacin can cause liver toxicity, necessitating periodic liver function tests. Massaging joints, limiting mobility aids, or drinking fruit juices (high in fructose) are not advised.

Question 4 of 5

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

A. Redness and edema noted at the incision site. B. Apical heart rate of 100 to 110 beats/minute. C. High-pitched sound heard upon inspiration. D. Pain rating of 8 on a scale of 0 to 10.

Correct Answer: C

Rationale: A high-pitched sound (stridor) indicates airway obstruction, a life-threatening emergency requiring immediate action. Other findings are expected or less urgent post-appendectomy.

Extract:

A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.