HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Absence of drainage in the collection chamber
- D. Fluid level in the suction control chamber is below the prescribed level
Correct answer: B
Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.
2. A client with liver cirrhosis is at risk for developing hepatic encephalopathy. Which clinical manifestation should the nurse monitor for?
- A. Kussmaul respirations
- B. Asterixis (flapping tremor)
- C. Bradycardia
- D. Hypertension
Correct answer: B
Rationale: Corrected Rationale: Asterixis, also known as a flapping tremor, is a common sign of hepatic encephalopathy, indicating neurological dysfunction due to liver failure. Kussmaul respirations (option A) are associated with metabolic acidosis, which is not a typical manifestation of hepatic encephalopathy. Bradycardia (option C) and hypertension (option D) are not typically associated with hepatic encephalopathy; in fact, hepatic encephalopathy is more commonly associated with alterations in mental status, neuromuscular abnormalities, and changes in behavior.
3. Which is a priority nursing intervention for the cognitively impaired child?
- A. The family will provide good nutrition.
- B. The family will provide loving interactions.
- C. Stimulation will improve.
- D. There will be contact with peers.
Correct answer: B
Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.
4. A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her BP is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for renal perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct answer: C
Rationale: Using an automated BP machine is crucial to continuously monitor for hypotension after administering an antihypertensive medication. This is essential to prevent a rapid drop in blood pressure that could lead to complications. Measuring urine output hourly to assess for renal perfusion is important but not the most immediate concern in this situation. Requesting pain medication is not relevant to the primary issue of managing blood pressure. Providing a quiet environment with low lighting may be beneficial for the client's overall well-being but is not as critical as monitoring for potential hypotension.
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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