Question

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Answer 1

Correct Answers:

Provide an eye shield to be worn while sleeping

Rationale :

🦺Wearing an eye shield after cataract surgery is a critical intervention during the immediate postoperative period to protect the surgical site from accidental rubbing or pressure during sleep.

🛌Older adult clients are at increased risk of unintentionally disturbing the surgical site, especially while asleep or disoriented post-anesthesia.

👁️Protecting the eye prevents complications like wound dehiscence, increased intraocular pressure, or lens displacement.

📋Immediate post-op care focuses on safety, not on teaching or deep breathing exercises which are not prioritized unless general anesthesia was used.

📌Core Message

Postoperative eye protection with a shield is a priority intervention to prevent injury after cataract surgery.

Answer 2

Correct Answers:

A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).

Rationale :

💧Pancreatitis often causes third spacing, leading to fluid loss and hemoconcentration, which is reflected in elevated BUN levels.

📉A drop in BUN after IV fluid therapy indicates effective rehydration and improved renal perfusion.

🧪BUN is a sensitive marker for intravascular volume status, especially in early stages of pancreatitis.

🩺Monitoring BUN trends helps assess response to fluid therapy and guides further treatment decisions.

📌Core Message

A decreasing BUN after IV fluid therapy signals successful hydration and improving pancreatitis management.

Answer 3

Correct Answers:

Neutrophil count.

Rationale :

🧬Wound enlargement in an immobile client could suggest an infection, making immune response evaluation critical.

🧫Neutrophils are the first responders to bacterial infections and a low or elevated count could provide clues to underlying pathology.

🔍A differential white blood cell count, especially absolute neutrophil count, helps assess for acute or chronic infection.

🛡️Early identification of infection risk supports prompt intervention to prevent complications like sepsis.

📌Core Message

A rising neutrophil count may signal infection and should be assessed when wound deterioration is observed.

Answer 4

Correct Answers:

Weigh yourself daily at the same time and report excessive weight loss.

Rationale :

⚖️Daily weight monitoring is essential in clients on diuretics to detect fluid shifts and prevent hypovolemia or fluid overload.

🕰️Weighing at the same time daily (preferably morning after voiding) ensures consistency in tracking trends.

🩺Weight loss beyond expected levels may indicate overdiuresis, which can cause dehydration and electrolyte imbalances.

📉Sudden weight changes are more reliable than subjective symptoms when managing diuretic therapy.

📌Core Message

Daily consistent weighing helps monitor the effectiveness and safety of diuretic therapy.

Answer 5

Correct Answers:

Fever and dysuria.

Rationale :

🌡️Fever and dysuria are hallmark symptoms of a urinary tract infection (UTI), increasing the risk for injury if untreated.

🚽Dysuria indicates lower tract irritation, while fever suggests systemic involvement or upper tract extension.

⚠️Clients with infection-related symptoms are at risk for complications such as sepsis or falls due to weakness/confusion.

📋Identifying UTI signs early supports timely treatment and reduces complication risk.

📌Core Message

Fever and dysuria signal a potential UTI, supporting a nursing diagnosis of injury risk.

Answer 6

Correct Answers:

333

Rationale :

🧪To calculate mg/mL, divide total drug amount by total solution volume: 1000 mg ÷ 3 mL = 333 mg/mL.

🧮Understanding concentration after reconstitution is essential for accurate dosing and safe administration.

💉This dose allows the nurse to extract the correct volume (in this case, 800 mg = approx. 2.4 mL) for the prescribed dose.

📊Dosage calculations must be precise to prevent underdosing or toxicity, especially with antibiotics.

📌Core Message

Accurate reconstitution calculations are vital for safe IM antibiotic dosing

Answer 7

Correct Answers:

Hypoventilation.

Rationale :

😮‍💨Hypoventilation is an immediate concern in hypothyroidism as it may indicate myxedema coma, a life-threatening emergency.

💤Reduced respiratory drive in severe hypothyroidism can lead to carbon dioxide retention and respiratory acidosis.

🛑This symptom requires urgent intervention, including respiratory support and hormone replacement.

🩺While other symptoms are typical, they are not immediately life-threatening like hypoventilation.

📌Core Message

Hypoventilation is a red flag for life-threatening complications in hypothyroidism and needs immediate care.

Answer 8

Correct Answers:

Remain upright following meals.

Rationale :

🪑GERD management emphasizes gravity to prevent reflux of gastric contents, especially after meals.

🧍‍♀️Staying upright promotes gastric emptying and minimizes pressure on the lower esophageal sphincter.

🍽️Postprandial positioning is more effective at preventing symptoms than dietary changes alone.

🧾This behavioral modification is a first-line, nonpharmacologic strategy in GERD self-care.

📌Core Message

Remaining upright post-meals is a key strategy in reducing GERD symptoms.

Answer 9

Correct Answers:

Complete a focused assessment of the abdomen.

Rationale :

🩺The priority post-biopsy is assessing for internal bleeding or perforation, especially with symptoms like rectal bleeding.

🧠A focused abdominal assessment helps identify early signs of complications such as rigidity, guarding, or tenderness.

⚠️This evaluation directs urgency and further care, especially in high-risk post-colonoscopy scenarios.

📋Early detection of internal issues improves outcomes and guides prompt intervention.

📌Core Message

A focused abdominal assessment is essential to detect complications after GI biopsy procedures.

Answer 10

Correct Answers:

Stone fragments are collected when straining the client's urine.

Rationale :

💎The goal of lithotripsy is to break up stones small enough to be passed in the urine.

🚽Collecting stone fragments indicates that fragmentation was successful and the kidney is clearing them.

🔍Straining urine is standard post-procedure to monitor for success and prevent future complications.

📈Monitoring for fragment passage helps evaluate the need for additional intervention.

📌Core Message

Presence of stone fragments in urine is the best indication that lithotripsy was effective.

HESI RN Medical-Surgical 2024 Exam-1

No.

1 :
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 :
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 :
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 :
The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 :
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 :
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

9 :
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 :
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

HESI RN Medical-Surgical 2024 Exam-1

No.

1 : An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 : While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 : The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 : The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 : The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 : The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

9 : An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 : While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

1 :
An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

3 :
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

4 :
The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

5 :
The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

7 :
The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

8 :
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

9 :
An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

10 :
While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?