HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse uses a diagram to show that the tetralogy of Fallot involves a combination of four congenital defects. What are the defects?
- A. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- B. Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, right ventricular hypertrophy
- D. Pulmonary stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct answer: B
Rationale: The correct answer is B: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy. Tetralogy of Fallot involves these four congenital defects. Choice A is incorrect because it includes aortic stenosis instead of pulmonary stenosis, atrial septal defect instead of ventricular septal defect, and left ventricular hypertrophy instead of right ventricular hypertrophy. Choice C is incorrect as it includes aortic stenosis and atrial septal defect instead of pulmonary stenosis and ventricular septal defect. Choice D is incorrect because it includes aortic hypertrophy instead of overriding aorta.
2. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
- A. Notify the healthcare provider of the findings.
- B. Ensure that the IV is infusing at the prescribed rate.
- C. Listen to lung sounds.
- D. Check under his back for evidence of bleeding.
Correct answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
3. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.
4. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in LOC
Correct answer: D
Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.
5. A woman with chronic osteoarthritis is complaining of knee pain. Which pathophysiological process is contributing to her pain?
- A. Inflammation of the synovial membrane.
- B. Degeneration of the cartilage in the joint.
- C. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
- D. Formation of uric acid crystals in the joint space.
Correct answer: C
Rationale: The correct answer is C. In osteoarthritis, the breakdown of cartilage in the joints leads to chondrocyte injury, which results in the destruction of joint cartilage and the production of osteophytes. This process causes joint inflammation and pain. Choice A is incorrect because osteoarthritis primarily involves the articular cartilage rather than the synovial membrane. Choice B is incorrect as it describes the degeneration of cartilage but does not explain the specific pathophysiological process contributing to pain in osteoarthritis. Choice D is incorrect as the formation of uric acid crystals is characteristic of gout, not osteoarthritis.
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