Medical Surgical HESI

HESI LPN

1. To assess the quality of an adult client’s pain, what approach should the nurse use?

A. Ask the client to rate the pain on a scale of 1 to 10.
B. Ask the client to describe the pain.
C. Observe the client’s nonverbal cues.
D. Determine the client’s pain tolerance.

Correct answer: B

Rationale: The correct approach for assessing the quality of an adult client's pain is to ask the client to describe the pain. By doing so, the nurse gains valuable information about the quality, location, and nature of the pain directly from the client. This approach allows for a more comprehensive understanding of the pain experience. Choice A, asking the client to rate the pain on a scale of 1 to 10, focuses more on intensity rather than quality. Choice C, observing the client's nonverbal cues, can provide additional information but may not fully capture the client's subjective experience of pain. Choice D, determining the client's pain tolerance, is not directly related to assessing the quality of pain but rather to how much pain a client can endure.

2. Laboratory findings indicate that a client’s serum potassium level is 2.5 mEq/L. What action should the nurse take?

A. Administer potassium supplements orally.
B. Increase the client's dietary potassium intake.
C. Inform the healthcare provider of the need for potassium replacement.
D. Monitor the client's ECG continuously.

Correct answer: C

Rationale: A serum potassium level of 2.5 mEq/L is critically low, indicating severe hypokalemia. In this situation, it is essential for the nurse to inform the healthcare provider promptly about the need for potassium replacement. Administering potassium supplements orally or increasing dietary potassium intake is not appropriate in cases of critically low potassium levels as immediate and precise replacement is necessary. Monitoring the client's ECG continuously is important in severe cases of hypokalemia, but the priority action should be to inform the healthcare provider for further management and treatment.

3. While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?

A. Irritation of nerve endings
B. Diminished blood flow
C. Ischemic tissue changes
D. Compression of a nerve

Correct answer: D

Rationale: The correct answer is D: Compression of a nerve. In carpal tunnel syndrome, pain arises from the compression of the median nerve within the carpal tunnel. This compression leads to symptoms such as pain, numbness, and tingling in the hand and arm. Choices A, B, and C are incorrect because carpal tunnel syndrome pain is primarily caused by the physical compression of the nerve, rather than irritation of nerve endings, diminished blood flow, or ischemic tissue changes.

4. While performing a skin assessment on an older adult, the nurse notices a number of irregular round brownish-colored lesions on the client’s hands, arms, and face. On palpation, they are flat and slightly rough to the touch. Based on this assessment finding, which action should the nurse implement?

A. Apply a topical antibiotic ointment.
B. Monitor the lesions for changes.
C. Advise the client to use sunscreen.
D. Refer the client for a skin lesion biopsy.

Correct answer: D

Rationale: Referral for a skin biopsy is necessary to rule out potential malignancy of irregular skin lesions. Applying a topical antibiotic ointment (Choice A) is not indicated for irregular pigmented lesions. Monitoring the lesions for changes (Choice B) may delay appropriate intervention if malignancy is present. Advising the client to use sunscreen (Choice C) is important for sun protection but is not the priority when irregular lesions are present.

5. A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the teaching plan?

A. Avoid taking folic acid supplements
B. Report any signs of infection immediately
C. Limit fluid intake to prevent edema
D. Increase intake of high-calcium foods

Correct answer: B

Rationale: The correct instruction that the nurse should include in the teaching plan for a client prescribed methotrexate is to report any signs of infection immediately. Methotrexate can suppress the immune system, making the individual more susceptible to infections. Reporting signs of infection promptly allows for timely intervention. Choices A, C, and D are incorrect. Avoiding folic acid supplements is not recommended because methotrexate can lead to folate deficiency, so supplementation may be necessary. There is no direct correlation between fluid intake limitation and methotrexate use. Increasing high-calcium foods is not specifically related to methotrexate therapy for rheumatoid arthritis.