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. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?
- A. Administer a sedative.
- B. Determine the client’s blood pressure.
- C. Apply soft restraints.
- D. Call for assistance.
Correct answer: B
Rationale: The correct intervention the nurse should implement first is to determine the client’s blood pressure. Assessing the blood pressure is crucial in this situation to rule out physiological causes like hypotension leading to the client's disorientation. Administering a sedative (Choice A) without understanding the underlying cause may worsen the situation. Applying soft restraints (Choice C) should not be the initial action and can be considered later if necessary. Calling for assistance (Choice D) may be needed eventually, but assessing the client's blood pressure takes precedence to address the immediate concern.
3. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
- A. Two liters.
- B. Three liters.
- C. Four liters.
- D. Five liters.
Correct answer: B
Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.
4. Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?
- A. Risk for infection related to thrombolysis.
- B. Risk for fluid volume deficit related to thrombolysis.
- C. Risk for impaired skin integrity related to thrombolysis.
- D. Risk for injury related to effects of thrombolysis.
Correct answer: D
Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.
5. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
- A. Morning headaches
- B. Pain for 3 consecutive months
- C. Febrile episodes in the late afternoon
- D. Diaphoresis when attacks occur
Correct answer: B
Rationale: The correct answer is B: Pain for 3 consecutive months. Recurrent abdominal pain (RAP) is characterized by abdominal pain that occurs at least once per week for at least 2 months before diagnosis. Choosing option A is incorrect since morning headaches are not a common characteristic of RAP. Option C is incorrect because febrile episodes in the late afternoon are not typically associated with RAP. Option D is incorrect as diaphoresis (excessive sweating) when attacks occur is not a common finding in RAP.
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