HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. What could suddenly occur in a child with acute epiglottitis?
- A. Increased carbon dioxide levels
- B. Airway obstruction
- C. Inability to swallow
- D. Bronchial collapse
Correct answer: B
Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.
2. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?
- A. Check the blood glucose level
- B. Administer insulin immediately
- C. Offer a high-protein snack
- D. Place the client in a supine position
Correct answer: A
Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.
3. 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.
4. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?
- A. Conductive
- B. Sensorineural
- C. Mixed
- D. Central
Correct answer: B
Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.
5. Based on the interpretation of this strip, what action should be implemented first?
- A. Call a code.
- B. Start CPR.
- C. Administer IV fluids.
- D. Apply oxygen.
Correct answer: A
Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.
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