Question

When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Answer 1

Correct Answers:

Apply a cold pack to the scrotal and penile areas.
Notify the healthcare provider immediately.

Rationale :

Apply a cold pack to the scrotal and penile areas

🔵 Cold application promotes vasoconstriction, which reduces blood flow, swelling, and inflammation in the affected area.

🔵 Postoperative edema is a common finding after a transurethral resection of the prostate (TURP), but it must be addressed promptly to prevent discomfort and complications.

🔵 Using a cold pack safely, wrapped in cloth, can provide localized pain relief without causing tissue injury.

🔵 Cold therapy is noninvasive and effective as a first-line nursing intervention for reducing edema.

🔵 It should be applied intermittently to prevent frostbite or skin damage.

Notify the healthcare provider immediately

🔵 Unexpected or significant edema of the scrotum and penis may indicate complications such as bleeding, hematoma, or impaired drainage post-TURP.

🔵 Immediate notification ensures timely medical assessment and potential changes in treatment to avoid deterioration.

🔵 The provider may need to evaluate for urinary retention, infection, or surgical complications.

🔵 Prompt communication with the provider is part of safe postoperative surveillance and nursing advocacy.

🔵 Early intervention may prevent progression to more severe outcomes such as tissue ischemia or urinary obstruction.

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Answer 2

Correct Answers:

History of suicide attempts.

Rationale :

🔷 Substance use disorders like heroin abuse are strongly associated with increased suicide risk, especially in clients with a past history of attempts.

🔷 A prior suicide attempt is one of the most reliable predictors of future suicidal behavior, requiring immediate safety planning.

🔷 Heroin use can intensify mood instability and increase impulsive behaviors, further elevating suicide risk.

🔷 The nurse must prioritize mental health stabilization by addressing the client's psychological safety first.

🔷 Integrating psychiatric assessment and monitoring into the care plan is vital to prevent self-harm.

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Answer 3

Correct Answers:

Brain damage with CP is not progressive but does have a variable course.

Rationale :

🔷 Cerebral palsy (CP) results from non-progressive brain injury, meaning the brain damage does not worsen over time.

🔷 While CP symptoms can appear to change or worsen, these are due to growth, developmental stages, or secondary complications—not progression of brain damage.

🔷 This clarification helps reassure parents and focus care on functional support and therapy, not halting a progressive process.

🔷 Treatment is aimed at maximizing abilities and minimizing complications like joint contractures or scoliosis.

🔷 Early intervention and consistent habilitative therapy support best outcomes.

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Answer 4

Correct Answers:

Withhold this dose.

Rationale :

🔷 If vomiting occurs shortly after digoxin administration in infants, the absorbed amount is unknown, making redosing unsafe.

🔷 Digoxin has a narrow therapeutic index, and repeated dosing can easily lead to toxicity.

🔷 Standard pediatric guidelines recommend skipping the dose and waiting until the next scheduled dose.

🔷 Common symptoms of toxicity (e.g., bradycardia, nausea, vomiting) may be difficult to detect in infants, increasing risk.

🔷 Parents should be instructed to report any signs of adverse reactions and avoid redosing without medical advice.

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Answer 5

Correct Answers:

Teach the need for dietary and supplemental vitamin D.

Rationale :

🔷 Burn clients, especially with extensive full-thickness burns, often have limited sun exposure and impaired vitamin D synthesis.

🔷 Vitamin D is essential for bone mineralization and muscle strength, and deficiency leads to symptoms like bone pain and weakness.

🔷 Supplementation addresses both nutritional and metabolic deficits common in long-term burn recovery.

🔷 Teaching the importance of dietary sources (e.g., fortified milk, fatty fish) and adherence to supplements enhances outcomes.

🔷 Long-term burn rehabilitation plans often include bone health monitoring to prevent osteoporosis or osteomalacia.

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Answer 6

Correct Answers:

Sedimentation rate
Anti-cyclic citrullinated peptide (anti-CCP) antibodies
C-reactive protein

Rationale :

Sedimentation rate (ESR)

🔶 The erythrocyte sedimentation rate is a nonspecific test that detects the presence and intensity of inflammation in the body.

🔶 In rheumatoid arthritis (RA), the ESR is typically elevated, indicating active disease and systemic inflammation.

🔶 ESR helps in both diagnosis and monitoring of disease progression or response to treatment.

🔶 Although not exclusive to RA, it provides valuable supportive evidence when combined with other RA-specific markers.

🔶 It is particularly useful during flare-ups to assess inflammation severity.

Anti-cyclic citrullinated peptide (anti-CCP) antibodies

🔶 Anti-CCP antibodies are highly specific to RA, making them a reliable biomarker for confirming the diagnosis.

🔶 Their presence often precedes the onset of clinical symptoms and may predict more severe joint damage.

🔶 Anti-CCP is useful in differentiating RA from other autoimmune or inflammatory conditions.

🔶 Detection of these antibodies is associated with early identification and aggressive disease management.

🔶 Including this test supports accurate clinical decision-making for treatment planning.

C-reactive protein (CRP)

🔶 CRP is a sensitive acute-phase reactant produced by the liver in response to systemic inflammation.

🔶 Elevated CRP levels correlate with disease activity in RA, especially during acute flares.

🔶 It is often used alongside ESR to monitor inflammatory changes and evaluate treatment effectiveness.

🔶 Persistent elevation in CRP may signal poor control of RA and the need to adjust therapy.

🔶 CRP is also valuable in predicting joint damage and long-term complications in RA patients.

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Answer 7

Correct Answers:

Advise to have a case management evaluation of the client's home environment.

Rationale :

🔷 A case manager performs a comprehensive evaluation of home care needs, assessing both client and caregiver roles.

🔷 This approach promotes individualized discharge planning, including respite care, rehab services, or in-home assistance.

🔷 It helps coordinate resources for the husband’s care while ensuring the client's post-op recovery is uninterrupted.

🔷 Patient-centered planning is essential for older adults balancing dual care responsibilities.

🔷 This recommendation facilitates safe recovery and continuity of both spousal care and therapy compliance.

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Answer 8

Correct Answers:

Watery diarrhea.

Rationale :

🔷 Linezolid carries a known risk of causing C. difficile-associated diarrhea, which can become life-threatening if untreated.

🔷 Early identification of watery diarrhea is critical to prevent toxic megacolon or sepsis in hospitalized patients.

🔷 The nurse must immediately notify the provider and stop the antibiotic if CDAD is suspected.

🔷 Diarrhea in clients receiving broad-spectrum antibiotics must always be assessed for infectious causes.

🔷 Further interventions include isolation precautions, stool testing, and fluid-electrolyte management.

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Answer 9

Correct Answers:

Monitor daily sodium intake.

Rationale :

🔷 SIADH leads to water retention and hyponatremia, making daily sodium monitoring essential.

🔷 Sodium imbalances can cause neurological symptoms, including confusion, seizures, and coma.

🔷 Fluid and electrolyte management is the cornerstone of care for SIADH patients.

🔷 Monitoring helps tailor fluid restriction or sodium replacement therapy.

🔷 Sodium trends guide the use of medications like demeclocycline or vasopressin antagonists.

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Answer 10

Correct Answers:

Elevated blood pressure must be anticipated and identified quickly.

Rationale :

🔷 Acute glomerulonephritis commonly results in fluid retention, leading to hypertension.

🔷 Frequent BP monitoring allows prompt treatment with antihypertensives or diuretics to prevent complications.

🔷 Hypertension in children can precipitate encephalopathy or seizures if unrecognized.

🔷 Nurses must be vigilant for subtle signs of elevated BP, especially in pediatric clients.

🔷 BP readings also help evaluate the effectiveness of fluid management strategies.

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RN HESI Exit~2023 Exam 3

No.

1 :
When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 :
During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 :
One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 :
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 :
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

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RN HESI Exit~2023 Exam 3

No.

1 : When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 : During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 : The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 : A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 : One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 : In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 : A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 : While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

1 :
When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

2 :
During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

3 :
The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

4 :
A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

5 :
One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in this client's plan of care?

8 :
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

9 :
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

10 :
While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?