HESI LPN
Medical Surgical Assignment Exam HESI
1. What is the best position for a client experiencing a nosebleed?
- A. Sitting up and leaning forward
- B. Lying flat with a pillow under the head
- C. Sitting up and leaning back
- D. Lying on the side with the head elevated
Correct answer: A
Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.
2. The nurse is triaging clients who have been injured during a tornado. Which client requires immediate action?
- A. A young male with a minor laceration on his forearm.
- B. An elderly woman with a dislocated shoulder who is calm.
- C. A middle-aged female with a broken humerus who is unable to follow commands and is crying.
- D. A teenager with abrasions and a bruised knee.
Correct answer: C
Rationale: The middle-aged female with a broken humerus who is unable to follow commands and is crying requires immediate action. These symptoms indicate a possible head injury or severe emotional distress that need urgent attention. Choice A is not as urgent since a minor laceration can be addressed after more critical cases. Choice B, although having a dislocated shoulder, is stable, as the client is calm. Choice D presents with minor injuries that can wait while more critical cases are addressed.
3. Which of the following is a priority assessment for a client receiving intravenous vancomycin?
- A. Respiratory rate
- B. Blood pressure
- C. Urine output
- D. Hearing acuity
Correct answer: D
Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.
4. 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.
5. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?
- A. The medication should be used for 10 weeks only.
- B. The medication requires that sexually active females use contraception.
- C. The medication lowers hemoglobin levels very quickly.
- D. The medication has few side effects.
Correct answer: B
Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.
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