HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. What is a priority action for the nurse when caring for a client with suspected meningitis?
- A. Isolate the client in a private room
- B. Administer intravenous antibiotics
- C. Obtain a throat culture
- D. Perform a chest x-ray
Correct answer: B
Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.
2. A community hit by a hurricane has suffered mass destruction and flooding. Several facilities are not functioning, and the area is contaminated with human excretions. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority?
- A. Administer prophylactic antibiotics as prescribed.
- B. Provide fluid and electrolyte replacement.
- C. Isolate all infectious diarrhea victims.
- D. Administer cholera vaccine.
Correct answer: B
Rationale: Providing fluid and electrolyte replacement is the highest priority to prevent dehydration and shock in clients with cholera. Administering prophylactic antibiotics may be necessary but is not the highest priority. Isolating infectious diarrhea victims is important for preventing the spread of infection, but addressing fluid and electrolyte imbalances takes precedence. Administering a cholera vaccine is preventive and not the immediate priority in treating clients already diagnosed with cholera.
3. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?
- A. Avoid cold temperatures completely.
- B. Take medications only during flare-ups.
- C. Wear gloves when removing packages from the freezer.
- D. Limit physical activity to avoid stress.
Correct answer: C
Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.
4. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
5. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time he took his medication?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours he slept last night?
Correct answer: B
Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.
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