a nurse cares for a client who has pyelonephritis the client states i am embarrassed to talk about my symptoms how should the nurse respond
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Nursing Elites

HESI RN

Evolve HESI Medical Surgical Practice Exam

1. A client has pyelonephritis and expresses embarrassment about discussing symptoms. How should the nurse respond?

Correct answer: C

Rationale: When a client expresses embarrassment or discomfort in discussing symptoms related to sensitive topics like elimination and the genitourinary area, the nurse should respond by encouraging the client to use words they are comfortable with. This helps the client feel more at ease and opens up communication. Offering a nurse of the same gender may not address the client's discomfort with discussing symptoms. Assuring confidentiality is important, but it should not be promised in a way that may not be fulfilled. Avoiding the topic of elimination entirely does not address the client's feelings or promote effective communication.

2. The client with chronic renal failure is on a fluid restriction. Which of the following statements by the client indicates that the teaching has been effective?

Correct answer: A

Rationale: Choice A is the correct answer because it demonstrates the client's understanding of the need to limit fluid intake to prevent fluid overload, which is crucial in managing chronic renal failure. Adequate fluid restriction is essential to prevent complications such as fluid overload and electrolyte imbalances. Choice B is incorrect as it promotes excessive fluid intake, which can worsen the client's condition by putting additional stress on the kidneys. Choice C is incorrect as skipping dialysis sessions can lead to a buildup of toxins in the body, worsening renal failure and potentially leading to life-threatening complications. Choice D is incorrect because limiting fluid intake to a specific volume may not be appropriate for all clients and can vary depending on individual needs, medical condition, and healthcare provider recommendations.

3. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?

Correct answer: A

Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.

4. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?

Correct answer: C

Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.

5. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

Correct answer: C

Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.

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