HESI LPN
Medical Surgical Assignment Exam HESI
1. What is a causative factor of Hirschsprung disease?
- A. Frequent evacuation of solids, liquid, and gases
- B. Excessive peristaltic movement
- C. The absence of parasympathetic ganglion cells in a portion of the colon
- D. One portion of the bowel telescoping into another
Correct answer: C
Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.
2. 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.
3. 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.
4. 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.
5. 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.
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