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Rhenis Nursing

HESI RN Med-Surg 2026 Exam-2

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1 :
A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

Avoid going barefoot, especially outside.

Use an astringent lotion for superficial bleeding.

Add large amounts of spinach to the diet

Take a multi-vitamin supplement daily.

Hint : 🧠Think about the safest way to reduce injury when a person is taking a blood thinner.

Correct Answers:

Avoid going barefoot, especially outside.

Rationale :

🩸Warfarin increases the risk for bleeding, so the most important discharge teaching focuses on injury prevention.

👣Avoiding walking barefoot lowers the chance of cuts, punctures, and trauma, which could lead to prolonged bleeding.

🍃Clients taking warfarin should keep vitamin K intake consistent, so adding large amounts of spinach would be unsafe teaching.

🛡️The best instruction is the one that directly helps prevent bleeding complications in daily life.

📌Core Message

The key teaching for warfarin is bleeding prevention, and avoiding barefoot walking helps reduce injury risk.

6 :
A nurse is caring for a patient.

A 65-year-old female arrived in the emergency department (ED) with symptoms of shortness of breath, feeling lightheaded, a heart rate that feels "funny," and swelling in both the legs and feet. She reports the symptoms started a week ago but have worsened in the last 24 hours. Has a surgical history of hysterectomy and hiatal hernia repair approximately 20 years ago. No smoking history. Takes medication for hypertension. Developed atrial fibrillation (A-fib) and has been on antiarrhythmic medication for approximately 10 years. Sees the cardiologist every 6 months for follow up and electrocardiogram (ECG) which she states is "OK." Admit to the hospital for monitoring.

1000

Assessment reveals crackles in lower bases bilaterally, heart rate is fast and irregular, S3 heart sounds heard per auscultation, 3+ edema in legs bilaterally.

1300

Admitted to telemetry medical surgical nursing unit. Peripheral IV (PIV) inserted in right forearm with 20 gauge catheter. Laboratory specimens drawn and sent for analysis. Weight 186 lb. (84.4 kg). Connected to telemetry monitor. Healthcare provider (HCP) notified for diet and medication for blood pressure and antiarrhythmic drug prescriptions.

1500

Weight 186 lb. (84.5 kg). Client reports normal weight is 175 lb. (79.4 kg) and has been at that weight for "a long time." Reports having voided only twice today. Becomes lightheaded and dizzy when standing. Crackles heard in all lung fields. Blood pressure 170/90 mm Hg. Edema noted at 3+ in lower extremities

1530

HCP notified of client worsening symptoms, laboratory and imaging study results. Prescription received.

1600

Administered furosemide 40 mg IV push (IVP) through PIV. Site with no signs or symptoms of inflammation. Flushed easily. Provided bed side commode for safety since client is dizzy when getting up.

2000

Has voided 3,500 mL clear urine in 4 hours. Client reports it is easier to breathe and not as dizzy. Edema in lower extremities 2+. Appears more alert but says she is feeling very tired.

1015

Admit to hospital

Chest x-ray

Echocardiogram (ECHO)

Insert peripheral IV (PIV) access device

Maintain PIV per facility protocol

Brain-type natriuretic peptide (BNP),

serum electrolytes,

blood urea nitrogen (BUN)

creatinine, complete blood count (CBC) with differential

1400

Rivaroxaban 20 mg PO once daily with evening meal

Heart healthy diet

Verapamil 140 mg PO twice daily

Daily weights

Clonidine 0.6 mg PO twice daily, hold if systolic blood pressure is less than 110 mm Hg

Reference Range

1500

BNP: 500 pg/mL (500 ng/L) — less than 100 pg/mL (100 ng/L)
Red blood cells (RBC): 3.5 × 10⁶/µL (3.5 × 10¹²/L) — 4.2 to 5.4 × 10⁶/µL (4.2 to 5.4 × 10¹²/L)
White blood cells (WBC): 5,000/mm³ (5 × 10⁹/L) — 5,000 to 10,000/mm³ (5 to 10 × 10⁹/L)
Blood urea nitrogen (BUN): 18 mg/dL (6.4 mmol/L) — 8 to 20 mg/dL (2.9 to 7.1 mmol/L)
Creatinine: 2.8 mg/dL (248 µmol/L) — 0.6 to 1.3 mg/dL (53 to 115 µmol/L)
Potassium: 4.5 mEq/L (4.5 mmol/L) — 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
Sodium: 150 mEq/L (150 mmol/L) — 136 to 145 mEq/L (136 to 145 mmol/L)

1000

Temperature: 98° F (36.8° C) orally

Heart rate: 94 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 156/92 mm Hg

1500

Heart rate: 90 beats/minute

Respirations: 24 breaths/minute

Blood pressure: 170/90 mm Hg

2000

Heart rate: 84 beats/minute

Respirations: 22 breaths/minute

Blood pressure: 148/82 mm Hg

The nurse is evaluating objective and subjective data to plan care for the client. For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client.

Body System	Renal	Cardiovascular	Respiratory
Monitor blood urea nitrogen (BUN) and creatinine
Strict intake and output
Assess edema
Monitor blood pressure
Provide medication education
Teach heart healthy diet
Assess for increased shortness of breath
Assess lung sounds

Hint : 🩺Match each intervention to the body system most directly affected by fluid overload and cardiac dysfunction.

Correct Answers

Monitor blood urea nitrogen (BUN) and creatinine [ Renal ]
Strict intake and output [ Renal ]
Assess edema [ Cardiovascular ]
Monitor blood pressure [ Cardiovascular ]
Provide medication education [ Cardiovascular ]
Teach heart healthy diet [ Cardiovascular ]
Assess for increased shortness of breath [ Respiratory ]
Assess lung sounds [ Respiratory ]

Rationale :

🧫The renal system must be monitored with BUN, creatinine, and intake/output because fluid shifts and diuretic therapy can affect kidney function.

❤️The cardiovascular system requires monitoring of edema and blood pressure because this client has heart failure, hypertension, and atrial fibrillation.

💊Teaching about medications and a heart healthy diet supports long-term control of cardiac workload and fluid status.

🌬️The respiratory system needs close assessment of shortness of breath and lung sounds because fluid backup can worsen pulmonary congestion.

📌Core Message

This client’s care should target renal monitoring, cardiovascular management, and respiratory assessment because heart failure affects all three systems.

Assessment Finding	Right HF	Left HF
Crackles in lower bases
Pulmonary edema
3+ leg edema
S3 heart sound
Shortness of breath

1 :
A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

3 :
A nurse is caring for a patient.

Correct Answers

4 :
A nurse is caring for a patient.

Correct Answers

5 :
A nurse is caring for a patient.

Answer Options

6 :
A nurse is caring for a patient.

Correct Answers

7 :
A nurse is caring for a patient.

Correct Answers

8 :
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

10 :
A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?

1 : A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

3 : A nurse is caring for a patient.

Correct Answers

4 : A nurse is caring for a patient.

Correct Answers

5 : A nurse is caring for a patient.

Answer Options

6 : A nurse is caring for a patient.

Correct Answers

7 : A nurse is caring for a patient.

Correct Answers

8 : A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

10 : A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?

1 :
A client is discharged with a prescription for warfarin. Which discharge instruction should the nurse emphasize to the client?

3 :
A nurse is caring for a patient.

4 :
A nurse is caring for a patient.

5 :
A nurse is caring for a patient.

6 :
A nurse is caring for a patient.

7 :
A nurse is caring for a patient.

8 :
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

10 :
A client receives a new prescription for simvastatin 5 mg PO daily at bedtime. Which action should the nurse take?