Medical Surgical Assignment Exam HESI

HESI LPN

Medical Surgical Assignment Exam HESI

1. 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.

2. A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?

A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough

Correct answer: A

Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.

3. 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.

4. A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?

A. Avoid foods high in vitamin C
B. Increase intake of green leafy vegetables
C. Limit intake of foods high in vitamin K
D. Avoid dairy products

Correct answer: C

Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.

5. 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.