HESI RN
HESI Medical Surgical Specialty Exam
1. A patient has begun taking spironolactone (Aldactone) in addition to a thiazide diuretic. With the addition of the spironolactone, the nurse will counsel this patient to
- A. not take a potassium supplement daily.
- B. recognize that abdominal cramping is a common side effect.
- C. report decreased urine output to the provider.
- D. take these medications in the morning.
Correct answer: C
Rationale: When combining a potassium-sparing diuretic like spironolactone with a thiazide diuretic, there is an increased risk of hyperkalemia, especially in patients with poor renal function. Therefore, the patient should be educated to report any decrease in urine output, which could indicate a potential issue with kidney function. Choice A is incorrect because taking additional potassium supplements can further increase the risk of hyperkalemia. Choice B is incorrect as abdominal cramping is not a common side effect of spironolactone. Choice D is incorrect because the timing of medication administration is not directly related to the addition of spironolactone and thiazide diuretic; there is no specific recommendation to take these medications only at bedtime.
2. A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.
- A. That informed consent is required
- B. That the test takes about 1 hour to complete
- C. That premedication for sedation may be necessary
- D. That food and fluids will be withheld before the procedure
Correct answer: B
Rationale: The correct answer is that the ERCP procedure takes about 1 hour to complete. Informed consent is required before the procedure. Premedication for sedation may be necessary as sedation is commonly used during ERCP to keep the client comfortable. Food and fluids are withheld before the procedure to prevent aspiration and ensure a clear view during the procedure. Position changes may be necessary to facilitate the passage of the tube.
3. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?
- A. Paralytic ileus
- B. Incisional pain
- C. Urine retention
- D. Nausea and vomiting
Correct answer: D
Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.
4. A patient who is being treated for dehydration is receiving 5% dextrose and 0.45% normal saline with 20 mEq/L potassium chloride at a rate of 125 mL/hour. The nurse assuming care for the patient reviews the patient’s serum electrolytes and notes a serum sodium level of 140 mEq/L and a serum potassium level of 3.6 mEq/L. The patient had a urine output of 250 mL during the last 12-hour shift. Which action will the nurse take?
- A. Contact the patient’s provider to discuss increasing the potassium chloride to 40 mEq/L.
- B. Continue the intravenous fluids as ordered and reassess the patient frequently.
- C. Notify the provider and discuss increasing the rate of fluids to 200 mL/hour.
- D. Stop the intravenous fluids and notify the provider of the assessment findings.
Correct answer: D
Rationale: The patient’s potassium level is within normal limits, but the decreased urine output indicates the patient should not receive additional IV potassium. Increasing potassium chloride to 40 mEq/L is not needed as the level is normal. Stopping the IV fluids is appropriate due to the decreased urine output, which suggests potential fluid overload. The nurse should notify the provider of the assessment findings for further management. Increasing the rate of fluids to 200 mL/hour is not recommended without addressing the decreased urine output first.
5. A client is being discharged after lithotripsy for a urinary calculus. Which statements should the nurse include in the discharge teaching? (Select all that apply.)
- A. Finish the prescribed antibiotic even if you are feeling better.
- B. Drink at least 3 liters of fluid each day.
- C. The bruising on your back may take several weeks to resolve.
- D. All of the above
Correct answer: D
Rationale: After lithotripsy for a urinary calculus, it is important for the client to complete the prescribed antibiotic course to prevent urinary tract infections. Drinking at least 3 liters of fluid daily helps dilute stone-forming crystals, prevent dehydration, and promote urine flow. Bruising on the back may occur after the procedure and can take several weeks to resolve. Additionally, the client may experience blood in the urine for several days post-procedure. Reporting any pain, fever, chills, or urination difficulties to the healthcare provider is essential, as these symptoms could indicate infection or stone formation. Choice D is correct as all the statements are appropriate for the client's discharge teaching. Choices A, B, and C are individually correct based on the rationale provided, making D the correct answer.
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