HESI Case Study: Benign Prostatic
Hyperplasia (BPH) Questions and Answers
Question 1
The client has continuous bladder irrigation (CBI) infusing with 0.9% sodium chloride.
Eight hours after surgery, the urinary drainage is reddish pink.
What action should the nurse take?
A. Notify the HCP of the drainage.
B. Stop the CBI and irrigate the catheter.
C. Increase the rate of flow of the CBI.
D. Document that the CBI is infusing correctly.
Correct Answer
D. Document that the CBI is infusing correctly.
Rationale: Normal drainage is reddish pink, clearing to light pink within 24 hours
postoperatively. The drainage should be clear yellow by the 4th postoperative day.
0.9% sodium chloride is the desired solution for irrigation because it is isotonic.
Hypotonic or hypertonic solutions may result in fluid shifts.
Question 4
Fill in the blank: The HCP prescribes an infusion of aminocaproic acid. The
prescription is for a loading dose of aminocaproic acid IV 5 grams to be infused in
250 mL of 5% dextrose over 1 hour. The tubing drop factor is 15 gtt/mL. How many
gtts/minute would the nurse set for the IV rate? (Enter numerical value only. If
rounding is necessary, round to the whole number.)
Correct Answer
63
Page 1 of 11
, Question 5
During administration of the aminocaproic acid infusion, the nurse monitors the client
for adverse effects of the medication.
What assessment data would indicate the onset of a thrombotic complication?
A. Frothy pink sputum.
B. Chest pain and dyspnea.
C. Wheezing and stridor.
D. Sudden high fever.
Correct Answer
B. Chest pain and dyspnea.
Rationale: Common manifestations of pulmonary embolism are chest pain and
dyspnea.
Question 6
Early the next morning, the nurse notes that the catheter is draining a large amount
of thick, bright red urine.
What actions should the nurse take? (Select all that apply.)
A. Ask the client to apply pressure by bearing down.
B. Release the tape traction on the catheter.
C. Increase the flow rate of the CBI.
D. Notify the HCP of the findings.
E. Perform manual irrigation.
Correct Answer
C. Increase the flow rate of the CBI.
D. Notify the HCP of the findings.
E. Perform manual irrigation.
Rationale: The flow rate of the CBI should be increased, to decrease the risk for
blood clot obstruction to the catheter.
Page 2 of 11
Hyperplasia (BPH) Questions and Answers
Question 1
The client has continuous bladder irrigation (CBI) infusing with 0.9% sodium chloride.
Eight hours after surgery, the urinary drainage is reddish pink.
What action should the nurse take?
A. Notify the HCP of the drainage.
B. Stop the CBI and irrigate the catheter.
C. Increase the rate of flow of the CBI.
D. Document that the CBI is infusing correctly.
Correct Answer
D. Document that the CBI is infusing correctly.
Rationale: Normal drainage is reddish pink, clearing to light pink within 24 hours
postoperatively. The drainage should be clear yellow by the 4th postoperative day.
0.9% sodium chloride is the desired solution for irrigation because it is isotonic.
Hypotonic or hypertonic solutions may result in fluid shifts.
Question 4
Fill in the blank: The HCP prescribes an infusion of aminocaproic acid. The
prescription is for a loading dose of aminocaproic acid IV 5 grams to be infused in
250 mL of 5% dextrose over 1 hour. The tubing drop factor is 15 gtt/mL. How many
gtts/minute would the nurse set for the IV rate? (Enter numerical value only. If
rounding is necessary, round to the whole number.)
Correct Answer
63
Page 1 of 11
, Question 5
During administration of the aminocaproic acid infusion, the nurse monitors the client
for adverse effects of the medication.
What assessment data would indicate the onset of a thrombotic complication?
A. Frothy pink sputum.
B. Chest pain and dyspnea.
C. Wheezing and stridor.
D. Sudden high fever.
Correct Answer
B. Chest pain and dyspnea.
Rationale: Common manifestations of pulmonary embolism are chest pain and
dyspnea.
Question 6
Early the next morning, the nurse notes that the catheter is draining a large amount
of thick, bright red urine.
What actions should the nurse take? (Select all that apply.)
A. Ask the client to apply pressure by bearing down.
B. Release the tape traction on the catheter.
C. Increase the flow rate of the CBI.
D. Notify the HCP of the findings.
E. Perform manual irrigation.
Correct Answer
C. Increase the flow rate of the CBI.
D. Notify the HCP of the findings.
E. Perform manual irrigation.
Rationale: The flow rate of the CBI should be increased, to decrease the risk for
blood clot obstruction to the catheter.
Page 2 of 11
