HESI RN
HESI Medical Surgical Assignment Exam
1. A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed. My bladder leaks like a young child’s bladder.” How should the nurse respond?
- A. I understand how you feel. I would be mortified.
- B. Incontinence pads will minimize leaks in public.
- C. I can teach you strategies to help control your incontinence.
- D. More women experience incontinence than you might think.
Correct answer: C
Rationale: The nurse should accept and acknowledge the client’s concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client’s concerns with the use of pads or stating statistics about the occurrence of incontinence.
2. A client with functional urinary incontinence is being taught by a nurse. Which statement should the nurse include in this client’s teaching?
- A. Clean around your catheter daily with soap and water.
- B. Wash the vaginal weights with a 10% bleach solution after each use.
- C. Informing about available operations to repair your bladder.
- D. Buy slacks with elastic waistbands that are easy to pull down.
Correct answer: D
Rationale: Functional urinary incontinence is not related to bladder issues but rather to difficulties with ambulation or accessing the toilet. The goal is to help the client manage clothing independently. Elastic waistband slacks that are easy to pull down facilitate timely access to the toilet. Choices A and B are unrelated and not applicable to functional urinary incontinence. Choice C is incorrect as surgeries to repair the bladder are not indicated for functional urinary incontinence.
3. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply.)
- A. Stress incontinence – Urine loss with physical exertion
- B. Urge incontinence – Large amount of urine with each occurrence
- C. Overflow incontinence – Constant dribbling of urine
- D. All of the above
Correct answer: D
Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.
4. The healthcare provider is caring for a patient who is receiving an intravenous antibiotic. The patient has a serum drug trough of 1.5 mcg/mL. The normal trough for this drug is 1.7 mcg/mL to 2.2 mcg/mL. What will the healthcare provider expect the patient to experience?
- A. Inadequate drug effects
- B. Increased risk of superinfection
- C. Minimal adverse effects
- D. Slowed onset of action
Correct answer: A
Rationale: A serum drug trough level below the normal range (1.7 mcg/mL to 2.2 mcg/mL) indicates that the medication concentration is insufficient to provide therapeutic effects, leading to inadequate drug effects. A low trough level does not directly correlate with an increased risk of superinfection, minimal adverse effects, or a slowed onset of action, as these are more related to the drug's concentration within the therapeutic range.
5. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient’s admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct?
- A. Administer the digoxin and monitor the patient’s electrocardiogram closely.
- B. Hold the digoxin dose and notify the provider of the patient’s lab values.
- C. Request an order for an intravenous bolus of potassium.
- D. Request an order for oral potassium supplements.
Correct answer: B
Rationale: In the scenario presented, the patient has a low serum potassium level, which can predispose the patient to digoxin toxicity. It is essential for the nurse to hold the digoxin dose and promptly notify the healthcare provider of the abnormal lab values. Option A is incorrect because administering digoxin without addressing the low potassium level can potentiate toxicity. Option C is inappropriate as potassium should not be given as an IV bolus, especially in the case of hypokalemia. Option D is incorrect because oral potassium supplements may not be sufficient for rapidly correcting severe hypokalemia in an acute care setting.
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