HESI Case Study - Benign Prostatic
Hyperplasia Questions and Answers
What action should the nurse take?
Correct Answer
Document that the CBI is infusing correctly.
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 2
What action should the nurse take?
Correct Answer
Stop the CBI, and irrigate the catheter.
The catheter is most likely obstructed by blood clots and should be manually
irrigated with 50 ml of sterile, 0.9% sodium chloride. The nurse should first check to
make sure there are no kinks in the drainage tubing or other obvious signs of
catheter obstruction!
Question 3
The client tells the nurse that he has cut back on drinking fluids to reduce symptoms.
Which instruction is most important for the nurse to provide to the client?
Correct Answer
Increase fluid intake to decrease the risk of developing a urinary tract infection.
Clients with BPH often restrict fluid intake to reduce symptoms, but this should be
discouraged because it increases the risk for urinary tract infection.
Page 1 of 10
, Question 4
Which nursing intervention best promotes effective communication by the charge
nurse?
Correct Answer
Review blood transfusion interventions with the nurse.
This is an assertive response by the charge nurse and offers both nurses an
opportunity to review the situation to determine variations from policy and any
evidence of negligence.
Question 5
Which of the client's serum laboratory values requires immediate intervention by the
nurse?
Correct Answer
Hematocrit 28 % (0.28)
Normal hematocrit is 37 - 46 % (0.37 - 0.46). A low hematocrit would be expected in
hypovolemic shock secondary to hemorrhage and requires immediate intervention.
Question 6
Which nursing intervention best promotes effective communication while teaching
the client about contracting pelvic floor muscles?
Correct Answer
Squeeze as if stopping the flow of urine.
This best describes how to contract the pelvic floor muscles. After holding the
contraction for 5 seconds, the client should relax for 5-10 seconds, and repeat 15-20
times TID. These exercises are also called Kegel exercises.
Page 2 of 10
Hyperplasia Questions and Answers
What action should the nurse take?
Correct Answer
Document that the CBI is infusing correctly.
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 2
What action should the nurse take?
Correct Answer
Stop the CBI, and irrigate the catheter.
The catheter is most likely obstructed by blood clots and should be manually
irrigated with 50 ml of sterile, 0.9% sodium chloride. The nurse should first check to
make sure there are no kinks in the drainage tubing or other obvious signs of
catheter obstruction!
Question 3
The client tells the nurse that he has cut back on drinking fluids to reduce symptoms.
Which instruction is most important for the nurse to provide to the client?
Correct Answer
Increase fluid intake to decrease the risk of developing a urinary tract infection.
Clients with BPH often restrict fluid intake to reduce symptoms, but this should be
discouraged because it increases the risk for urinary tract infection.
Page 1 of 10
, Question 4
Which nursing intervention best promotes effective communication by the charge
nurse?
Correct Answer
Review blood transfusion interventions with the nurse.
This is an assertive response by the charge nurse and offers both nurses an
opportunity to review the situation to determine variations from policy and any
evidence of negligence.
Question 5
Which of the client's serum laboratory values requires immediate intervention by the
nurse?
Correct Answer
Hematocrit 28 % (0.28)
Normal hematocrit is 37 - 46 % (0.37 - 0.46). A low hematocrit would be expected in
hypovolemic shock secondary to hemorrhage and requires immediate intervention.
Question 6
Which nursing intervention best promotes effective communication while teaching
the client about contracting pelvic floor muscles?
Correct Answer
Squeeze as if stopping the flow of urine.
This best describes how to contract the pelvic floor muscles. After holding the
contraction for 5 seconds, the client should relax for 5-10 seconds, and repeat 15-20
times TID. These exercises are also called Kegel exercises.
Page 2 of 10
