HESI LPN
Medical Surgical HESI 2023
1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?
- A. Obtain a wound specimen for culture.
- B. Initiate an infusion of intravenous (IV) fluids.
- C. Transfer the client to the ICU.
- D. Assess the client's core temperature.
Correct answer: B
Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.
2. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?
- A. 100 mL/hour.
- B. 125 mL/hour.
- C. 133 mL/hour.
- D. 150 mL/hour.
Correct answer: C
Rationale: To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour). Therefore, choice C is the correct answer. Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.
3. A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?
- A. Report any signs of a sore throat or fever immediately
- B. Take the medication with antacids to reduce stomach upset
- C. Discontinue the medication if you feel drowsy
- D. Increase the dosage if you experience an aura
Correct answer: A
Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention. Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption. Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time. Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.
4. What is the priority patient problem for the parents of a newborn born with cleft lip and palate?
- A. Parental role conflict
- B. Risk for delayed growth and development
- C. Risk for impaired attachment
- D. Anticipatory grieving
Correct answer: C
Rationale: The correct answer is C: Risk for impaired attachment. Parents of a newborn with cleft lip and palate may face challenges in bonding with their child due to the physical appearance, impacting attachment. Promoting bonding between parents and the infant is crucial in this situation. Choice A (Parental role conflict) is incorrect as it focuses on conflicting roles rather than the attachment issue. Choice B (Risk for delayed growth and development) is not the priority issue in this scenario as the immediate concern is establishing a healthy attachment. Choice D (Anticipatory grieving) is not the priority patient problem as it pertains more to the emotional response to an anticipated loss, which is not the primary concern at this stage.
5. What pathophysiologic process is producing the symptoms of gout in a client with sudden onset of big toe joint pain and swelling?
- A. Deposition of crystals in the synovial space of the joints produces inflammation and irritation.
- B. Degeneration of joint cartilage causing inflammation.
- C. Infection of the joint space leading to inflammation.
- D. Increased synovial fluid causing joint swelling and pain.
Correct answer: A
Rationale: The correct answer is A. Gout is characterized by the deposition of uric acid crystals in the synovial fluid of joints, which triggers inflammation and pain. This process is known as crystal-induced arthritis. Choice B is incorrect as gout does not involve degeneration of joint cartilage. Choice C is incorrect as gout is not caused by an infection of the joint space. Choice D is incorrect as gout does not result from increased synovial fluid but rather from the deposition of uric acid crystals.
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