HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?
- A. Ensure patency of an indwelling catheter and measure hourly intake and output.
- B. Prepare for cessation of the anesthesia and the surgical procedure.
- C. Obtain specimens of ABGs and serum electrolytes.
- D. Initiate cooling measures using iced normal saline by nasogastric lavage.
Correct answer: B
Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.
2. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?
- A. Light yellow coloring of the client's skin and eyes.
- B. The client's blood pressure reading of 184/88 mm Hg.
- C. The client vomits 20 ml of clear yellowish fluid.
- D. The IV insertion site is red, swollen, and leaking IV fluid.
Correct answer: B
Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.
3. The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?
- A. Applesauce
- B. White rice
- C. Coffee
- D. Bananas
Correct answer: C
Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.
4. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
- A. Osmolarity
- B. Glucose
- C. Albumin
- D. Platelets
Correct answer: B
Rationale: The correct answer is B: Glucose. Hydrocortisone can lead to increased blood glucose levels, so monitoring glucose is crucial to assess for hyperglycemia, a common side effect of corticosteroid therapy. Monitoring osmolarity (choice A) is not typically indicated in this scenario. Albumin (choice C) and platelets (choice D) are not directly affected by hydrocortisone therapy and are not the primary focus of monitoring in this case.
5. The family of a newly admitted child with cystic fibrosis is educated by the nurse that the treatment will be centered on what therapy?
- A. Chest physiotherapy
- B. Mucus-drying agents
- C. Prevention of diarrhea
- D. Insulin therapy
Correct answer: A
Rationale: The correct answer is A: Chest physiotherapy. In cystic fibrosis, chest physiotherapy and aerosol medications are fundamental components of treatment to help clear mucus from the lungs, reduce the risk of infections, and improve breathing. Mucus-drying agents (Choice B) are not typically used in the treatment of cystic fibrosis. Prevention of diarrhea (Choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (Choice D) is not relevant to cystic fibrosis, as it is a treatment for diabetes.
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