HESI LPN
Medical Surgical HESI
1. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation?
- A. Impaired skin integrity
- B. Fluid volume excess
- C. Acute pain and anxiety
- D. Peripheral neurovascular dysfunction
Correct answer: A
Rationale: The correct answer is A: Impaired skin integrity. In this situation, the greatest clinical risk is related to impaired skin integrity due to the potential extravasation of the vesicant. Vesicants are substances that can cause severe tissue damage if they leak into the surrounding tissues. Choices B, C, and D are not the most significant risks in this scenario. Fluid volume excess, acute pain, and peripheral neurovascular dysfunction are not directly associated with leaving the IV in place with a known vesicant for an extended period.
2. The nurse is caring for a client with acute pancreatitis. Which laboratory result is most indicative of this condition?
- A. Elevated serum amylase
- B. Decreased serum bilirubin
- C. Increased blood urea nitrogen (BUN)
- D. Decreased alkaline phosphatase
Correct answer: A
Rationale: Elevated serum amylase is the most indicative laboratory result of acute pancreatitis. In this condition, the pancreas becomes inflamed, leading to the leakage of amylase and lipase into the bloodstream. Elevated serum amylase levels are a classic finding in acute pancreatitis. Choices B, C, and D are not typically associated with acute pancreatitis. Decreased serum bilirubin, increased blood urea nitrogen (BUN), and decreased alkaline phosphatase levels are not specific markers for acute pancreatitis.
3. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?
- A. Remove all sources of liquids from the client's room
- B. Allow family to give the client a measured amount of ice chips
- C. Restrict family visiting until the client's condition is stable
- D. Provide the client with oral swabs to moisten his mouth
Correct answer: D
Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.
4. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?
- A. Are you sure your child has iron deficiency anemia?
- B. This happens when the maternal stores of iron are depleted at about 6 months.
- C. This anemia is caused by blood loss.
- D. The child may not have had it for a long time.
Correct answer: B
Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.
5. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line?
- A. Straw
- B. Spoon
- C. Syringe
- D. Cup
Correct answer: D
Rationale: Following surgical repair of a cleft palate, a cup should be used to prevent injury to the suture line. Utensils such as straws, spoons, droppers, and syringes should be avoided as they can cause trauma to the surgical site. Using a cup reduces the risk of disrupting the sutures and promotes proper healing.
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