HESI MEDICAL SURGICAL ACTUAL EXAM QUESTIONS WITH DETAILED RATIONALE
When planning care for a client with right renal calculi, which nursing diagnosis has the
highest priority?
Acute pain related to movement of the stone.
Impaired urinary elimination related to obstructed flow of urine.
Risk for infection related to urinary stasis.
Deficient knowledge related to need for prevention of recurrence of calculi.
Rationale
The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's
movement".
The nurse is caring for a client with non-Hodgkin’s lymphoma who is receiving
chemotherapy.
Laboratory results reveal a platelet count of 10,000/ml. What action should the nurse
implement?
Encourage fluids to 3000 ml/day.
Check stools for occult blood.
Provide oral hygiene every 2 hours.
Check for fever every 4 hours.
Rationale
Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side
effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for
occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone
and asks the nurse how long will antibiotics have to be administered. Which information
should the nurse communicate?
Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks.