HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?
- A. I need to take the prescribed amount of the drug to get rid of my gout.
- B. I need to take this drug every day to keep from having any flare-ups.
- C. I should take this drug when I have gout attacks to reduce symptoms.
- D. The pain and swelling can be controlled by taking this drug every day.
Correct answer: B
Rationale: Taking allopurinol every day helps to prevent gout flare-ups by reducing uric acid levels.
2. What should be included in the medical management of sickle cell crisis?
- A. Information for the parents including home care
- B. Provisions for adequate hydration and pain management
- C. Pain management and administration of iron supplements
- D. Adequate oxygenation and factor VIII
Correct answer: B
Rationale: The correct answer is B: Provisions for adequate hydration and pain management. In managing a sickle cell crisis, it is essential to provide adequate hydration to prevent further sickling of red blood cells and ensure proper pain management to alleviate the severe pain associated with the crisis. While information for parents and home care may be important aspects of overall care, they are not specific to the immediate medical management of a sickle cell crisis. Administration of iron supplements is not recommended during a sickle cell crisis as it can potentially worsen the condition by promoting the production of more sickled red blood cells. Adequate oxygenation is crucial in sickle cell disease, but factor VIII is not typically part of the management of a sickle cell crisis.
3. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?
- A. Assist with referral to specialized education.
- B. Support the child with independent toileting.
- C. Assist the child to develop effective communication.
- D. Encourage the child to ambulate independently.
Correct answer: C
Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.
4. What is the major criterion for diagnosing cognitive impairment in a child?
- A. An IQ of 75 or less
- B. Subaverage functioning
- C. An IQ of 70 or less
- D. Onset before 18
Correct answer: C
Rationale: The correct criterion for diagnosing cognitive impairment in a child is having an IQ of 70 or less. This range is typically used to define cognitive impairment in children. Choice A ('An IQ of 75 or less') is incorrect as the threshold is generally set at 70 or below. Choice B ('Subaverage functioning') is vague and does not specifically address the IQ criterion. Choice D ('Onset before 18') is unrelated to the primary criterion of IQ level used in diagnosing cognitive impairment in children.
5. Which finding should the nurse report immediately for a client receiving a blood transfusion?
- A. Mild itching and rash
- B. Temperature increase of 1.5°F (0.8°C)
- C. Heart rate increase of 10 beats per minute
- D. Slight headache
Correct answer: B
Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.
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