HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
- A. Avoid coiling the tubing and keep it free of kinks.
- B. Cleanse the perineal area with soap and water twice daily.
- C. Keep the drainage bag lower than the level of the bladder.
- D. Drink 1,000 ml of fluids daily to irrigate the catheter.
Correct answer: C
Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.
2. A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea/vomiting. The examining healthcare provider believes that the client has experienced an acute myocardial infarction (AMI) within the past three hours and would like to initiate tissue plasminogen activator (tPA) therapy. Which client history findings contraindicate the use of tPA?
- A. Treats hypoglycemia with an oral hypoglycemic agent.
- B. Had a cerebrovascular hemorrhage 2 months ago.
- C. Current age 65, father died of MI at 55.
- D. Report of being intolerant of medication that contains aspirin.
Correct answer: B
Rationale: A history of cerebrovascular hemorrhage is a contraindication for tPA therapy due to the risk of bleeding. Choice A is incorrect because treating hypoglycemia with an oral hypoglycemic agent is not a contraindication for tPA therapy. Choice C is incorrect as age and family history of MI do not contraindicate the use of tPA. Choice D is incorrect as being intolerant of medication containing aspirin is not a contraindication for tPA therapy.
3. A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?
- A. Administer antihypertensive medication as prescribed.
- B. Place the client in a supine position.
- C. Obtain a detailed health history.
- D. Monitor urine output.
Correct answer: A
Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.
4. The healthcare provider prescribes the nonsteroidal anti-inflammatory drug (NSAID) naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During a follow-up visit one month later, the client tells the nurse, 'The pills don't seem to be working. They are not helping the pain at all.' Which factor should influence the nurse’s response?
- A. Noncompliance is probably impacting the optimum medication effectiveness.
- B. Drug dosage is inadequate and needs to be increased to four times a day.
- C. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream.
- D. NSAID response is variable, and another NSAID may be more effective.
Correct answer: D
Rationale: The correct answer is D. NSAID response can vary among individuals, and sometimes a different NSAID may be more effective for a specific client. In this case, since the current NSAID (naproxen) is not providing pain relief, it is reasonable to consider switching to another NSAID. Choice A is incorrect because there is no information provided to suggest noncompliance. Choice B is incorrect as increasing the dosage without assessing the response may lead to unnecessary side effects. Choice C is incorrect because although it may take time for NSAIDs to reach therapeutic levels, lack of pain relief after a month is a valid reason to consider changing the medication rather than waiting longer.
5. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?
- A. Hypotension
- B. Tachycardia
- C. Severe headache
- D. Flushed skin below the level of injury
Correct answer: C
Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.
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