after a myocardial infarction the hospitalized client is taught to move the legs while resting in bed the expected outcome of this exercise is to
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Nursing Elites

HESI RN

HESI Medical Surgical Exam

1. 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.

2. A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

Correct answer: A

Rationale: A weight loss of 11 pounds in the past 10 days indicates fluid loss, a positive response to treatment for acute glomerulonephritis. It signifies that the glomeruli are functioning adequately to filter excess fluid. A urine specific gravity of 1.048 is high, indicating concentrated urine, which is not a positive response in this context. Blood in the urine is not a typical finding in glomerulonephritis, so its absence is expected and does not indicate a positive response to treatment. A blood pressure of 152/88 mm Hg is elevated and may suggest kidney damage or fluid overload, which are not positive responses to treatment.

3. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

Correct answer: C

Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.

4. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct answer: C

Rationale: Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.

5. What information will the nurse provide when counseling a patient starting a sulfonamide drug for a urinary tract infection?

Correct answer: A

Rationale: The correct answer is A: Drink several quarts of water daily. This advice aims to prevent crystalluria, a potential side effect of sulfonamide drugs. Option B is incorrect because antacids should not be taken with sulfonamides as they can decrease drug absorption. Option C is incorrect as sulfonamides can increase sensitivity to sunlight, not requiring sun exposure limitations but sun protection measures. Option D is incorrect because a sore throat could indicate a more serious adverse effect and should be promptly reported for evaluation.

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