HESI RN Medical Surgical Nursing

HESI RN Medical Surgical Nursing Related

Review HESI RN Medical Surgical Nursing related questions and content

Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.

The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which 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 progress.

  • A. Actions to Take
    Choices
    A. Request prescription for external catheter device
    B. Request prescription for straight catheter
    C. Insert indwelling urinary catheter
    D. Assist client to bathroom for voiding
    E. Increase the IV fluid rate
  • B. Potential Condition
    Choices
    A. Urinary Retention
    B. Urinary tract obstruction
    C. Overflow Urinary Incontinence
    D. IV fluid intake
    E. Frequency of voiding
  • C. Parameters to monitor
    Choices
    A. Amount of urine output
    B. Residual urine
    C. Pain medication effects
    D. IV fluid intake
    E. Frequency of voiding
Correct Answer: A

Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.

You may also like to solve these questions

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

  • A. First voided specimen in the morning.
  • B. A clean catch specimen.
  • C. Any specimen voided after drinking adequate fluids.
  • D. A 24-hour specimen.
Correct Answer: B

Rationale: A clean catch specimen minimizes contamination, providing accurate results for diagnosing urethritis, unlike other methods.

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

  • A. Watch for shortness of breath which may indicate a fat embolus.
  • B. Begin range of motion exercises within the first 24 hours.
  • C. Apply ice intermittently for the first 24 hours.
  • D. After edema subsides, apply heat continuously.
Correct Answer: C

Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.

The nurse establishes a nursing problem of 'Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis.' Which nursing intervention should the nurse include in the plan of care for this client?

  • A. Assist the client with learning how to set priorities and pace activities.
  • B. Instruct the client about the importance of maintaining bedrest.
  • C. Consult the discharge planner about transferring the client to an assisted living center.
  • D. Offer assurance that the fatigue inducing stage of the disease does not last.
Correct Answer: A

Rationale: Pacing activities balances exertion and rest, reducing fatigue in rheumatoid arthritis, unlike bedrest, relocation, or reassurance.

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

  • A. Stone fragments are collected when straining the client's urine.
  • B. Client denies urinary frequency, urgency, or dysuria.
  • C. Urine is pale pink with no observable blood clots.
  • D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.
Correct Answer: A

Rationale: Collecting stone fragments directly confirms the success of lithotripsy in breaking down the stone, unlike symptom relief or lab values.

A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

  • A. Place an indwelling urinary catheter and attach a bedside drainage unit.
  • B. Send the client to x-ray for a flat plate of the abdomen.
  • C. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
  • D. Give a prescribed analgesic for temperature above 101° F (38.3°C).
Correct Answer: C

Rationale: An NGT decompresses the stomach, addressing potential bowel obstruction indicated by vomiting and hyperactive bowel sounds.

Copyright © 2025 Nokea. All rights reserved.