HESI LPN
HESI Test Bank Medical Surgical Nursing
1. 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.
2. 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.
3. What information should the nurse include in the teaching plan of a client diagnosed with GERD?
- A. Sleep without using pillows
- B. Opt for five small meals throughout the day instead of three full meals with no snacks
- C. Minimize symptoms by wearing loose, comfortable clothing
- D. Engage in low-impact exercises like walking or swimming
Correct answer: C
Rationale: The correct answer is C: 'Minimize symptoms by wearing loose, comfortable clothing.' Wearing loose, comfortable clothing can help reduce pressure on the abdomen, which can alleviate GERD symptoms. Option A is incorrect as sleeping without using pillows is not a recommended practice for managing GERD. Option B is incorrect because it suggests adjusting food intake to five small meals throughout the day instead of three full meals with no snacks, which may not be suitable for everyone with GERD. Option D is incorrect as avoiding participation in any aerobic exercise program is not a standard recommendation for managing GERD; in fact, engaging in low-impact exercises like walking or swimming can be beneficial.
4. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct answer: A
Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.
5. When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?
- A. Limited eye movement.
- B. Decreased peripheral vision.
- C. Blurred distance vision.
- D. Photosensitivity.
Correct answer: B
Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.
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