HESI Medical Surgical Practice Quiz

Correct Answer: C

Rationale: For a client with a history of calcium phosphate urinary stones, it is essential to limit the intake of foods high in animal protein to prevent the formation of stones. Additionally, reducing sodium intake is crucial as high sodium levels can contribute to stone formation. Therefore, choices A and B are correct. Choice D, which suggests reducing intake of milk and other dairy products, is not specifically recommended for calcium phosphate stones. Clients with calcium phosphate stones should focus on limiting animal protein, sodium, and calcium intake. Choices A and B address these dietary modifications, making them the correct options for this client. Choices D, which is not directly related to calcium phosphate stones, is incorrect.

Correct Answer: C

Rationale: In this scenario, the patient is experiencing symptoms of digoxin toxicity, such as blurred vision and bradycardia. When thiazide diuretics like hydrochlorothiazide are taken with digoxin, the patient is at risk of digoxin toxicity due to the potential for thiazides to cause hypokalemia. Therefore, the correct action for the nurse to take is to hold the digoxin and notify the provider. Administering the medications without addressing the potential toxicity could worsen the patient's condition. Requesting serum electrolytes (Choice A) may be necessary but holding the digoxin takes priority. Evaluating serum blood glucose (Choice B) is not relevant to the current situation. Holding hydrochlorothiazide (Choice D) is not the best option as the primary concern is the digoxin toxicity that needs to be addressed promptly.

Correct Answer: D

Rationale: A urine specific gravity of 1.040 is higher than the normal range (1.005 to 1.030) and can indicate dehydration, decreased kidney blood flow, or the presence of antidiuretic hormone. In this situation, the priority action should be to increase the client's fluid intake to address the high specific gravity. Obtaining a urine culture, placing the client on restricted fluids, or assessing the creatinine level would not directly address the underlying issue of high urine specific gravity caused by dehydration or other factors.

Correct Answer: D

Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.

Correct Answer: D

Rationale: The correct action for the nurse to take in this situation is to assess the client's abdomen and vital signs. The nephrostomy tube should have a consistent amount of drainage, and a decrease may indicate obstruction. Before notifying the provider, the nurse must assess the client for pain, distention, and changes in vital signs. This assessment is crucial to gather essential information to report accurately. Documenting the finding without further assessment may delay necessary intervention. Evaluating the tube as working in the hand-off report or clamping the tube prematurely are not appropriate actions and could lead to complications if there is an obstruction.