HESI LPN
HESI Test Bank Medical Surgical Nursing
1. While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the nurse implement first?
- A. Prepare for cardiac defibrillation.
- B. Apply cardiac monitor leads.
- C. Obtain troponin serum levels.
- D. Palpate the client’s artery.
Correct answer: D
Rationale: Palpating the client's artery is the priority intervention in this scenario because it helps determine if there is a pulse, which is crucial information in emergency situations like this. If the client is pulseless, immediate initiation of CPR is necessary. Applying cardiac monitor leads or obtaining troponin serum levels can wait until the presence of a pulse is confirmed. Cardiac defibrillation is not indicated without first assessing the client's pulse and cardiac rhythm.
2. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?
- A. Administer prescribed pain medication.
- B. Notify the healthcare provider immediately.
- C. Place an eye patch over the affected eye.
- D. Prepare the client for a CT scan.
Correct answer: B
Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.
3. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
- A. Shallow open ulcer with a red-pink wound bed.
- B. Intact skin with non-blanchable redness.
- C. Full-thickness tissue loss with visible fat.
- D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct answer: A
Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.
4. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?
- A. Keep the arm and shoulder of the affected side immobile at all times.
- B. Encourage the client to breathe deeply and cough at frequent intervals.
- C. Maintain the pleura vac slightly above the chest level.
- D. Ensure there is no fluctuation in the water seal.
Correct answer: B
Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.
5. The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?
- A. Check the BP every five minutes for one hour.
- B. Raise the HOB 60 to 90 degrees.
- C. Ask the client to cough and deep breathe.
- D. Take the client’s temperature using another method.
Correct answer: D
Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.
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