HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?
- A. Mild soap and water
- B. A cotton ball
- C. Mineral oil
- D. Alcohol swabs
Correct answer: C
Rationale: To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (Choice A) may not be effective in completely removing zinc oxide. A cotton ball (Choice B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (Choice D) can be harsh on the skin and are not recommended for this purpose.
2. What is a causative factor of Hirschsprung disease?
- A. Frequent evacuation of solids, liquid, and gases
- B. Excessive peristaltic movement
- C. The absence of parasympathetic ganglion cells in a portion of the colon
- D. One portion of the bowel telescoping into another
Correct answer: C
Rationale: The correct answer is C: The absence of parasympathetic ganglion cells in a portion of the colon is a causative factor of Hirschsprung disease. This absence leads to the inability of the affected segment of the colon to relax, causing a functional obstruction. Choices A, B, and D are incorrect. Frequent evacuation of solids, liquid, and gases, excessive peristaltic movement, and one portion of the bowel telescoping into another are not causative factors of Hirschsprung disease.
3. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?
- A. Avoid cold temperatures completely.
- B. Take medications only during flare-ups.
- C. Wear gloves when removing packages from the freezer.
- D. Limit physical activity to avoid stress.
Correct answer: C
Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.
4. 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.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?
- A. Increased respiratory rate
- B. Decreased level of consciousness
- C. Improved oxygen saturation
- D. Complaints of dry mouth
Correct answer: B
Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.
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