HESI LPN
Medical Surgical Assignment Exam HESI
1. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?
- A. Elevated temperature
- B. Generalized weakness
- C. Diminished lung sounds
- D. Pain when swallowing
Correct answer: D
Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.
2. During the initial assessment of an older male client with obesity and diabetes who develops intermittent claudication, which additional information obtained by the nurse is most significant?
- A. Smokes 1.5 packs of cigarettes daily.
- B. Exercises regularly.
- C. Has a high-fat diet.
- D. Consumes alcohol daily.
Correct answer: A
Rationale: The correct answer is A: 'Smokes 1.5 packs of cigarettes daily.' Smoking is a significant risk factor for peripheral arterial disease, a condition that can lead to intermittent claudication. The nicotine and other chemicals in cigarettes can damage blood vessels, leading to reduced blood flow and increased risk of developing circulation problems. Choices B, C, and D are less significant in the context of intermittent claudication. Regular exercise, a high-fat diet, and daily alcohol consumption may have health implications, but they are not as directly linked to the development of intermittent claudication in the presence of obesity, diabetes, and smoking.
3. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?
- A. Encourage the client to eat quickly.
- B. Provide a straw for liquids.
- C. Place the client in an upright position during meals.
- D. Offer thin liquids.
Correct answer: C
Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.
4. The nurse is reviewing blood pressure readings for a group of clients on a medical unit. Which client is at the highest risk for complications related to hypertension?
- A. Post-menopausal Caucasian female who overeats and is 20% above her ideal body weight.
- B. Young adult Hispanic female who has hemoglobin at 11 g/dl (110 g/L) and drinks beer daily.
- C. Older adult who consumes a diet of smoked, cured, and pickled foods.
- D. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL (256.4 micromol/L).
Correct answer: D
Rationale: The correct answer is D. An elevated serum creatinine level indicates kidney damage, which significantly increases the risk of complications from hypertension. High blood pressure can damage the kidneys over time, leading to impaired kidney function. Choices A, B, and C do not directly correlate with increased risk of complications related to hypertension. Choice A focuses on obesity and overeating, Choice B on anemia and alcohol consumption, and Choice C on a diet high in sodium and nitrates, none of which are as directly related to hypertension complications as kidney damage.
5. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?
- A. Apical pulse 58 bpm.
- B. Core body temperature 100.8°F.
- C. Tachypnea with dyspnea.
- D. Multiple bruises over the chest area.
Correct answer: C
Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.
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