HESI RN
HESI Maternity Test Bank
1. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?
- A. Which symptom did you experience first?
- B. Are you consuming large amounts of salty foods?
- C. Have you traveled to a foreign country recently?
- D. Do you have a history of rheumatic fever?
Correct answer: D
Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.
2. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?
- A. Assess the severity and location of the pain
- B. Obtain an order for an analgesic
- C. Reassure the client that this is not unusual for his age
- D. Encourage the client to increase activity
Correct answer: A
Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.
3. Practices such as female genital mutilation and unsafe male circumcision are categorized as:
- A. Harmful traditional practices
- B. Encouraged in rural Zambia
- C. Recommended in modern surgery and IRH
- D. Safer sex practices
Correct answer: A
Rationale: Practices like female genital mutilation and unsafe male circumcision are considered harmful traditional practices due to the physical and psychological harm they cause. Choice A is correct as these practices are not safe or recommended. Choice B is incorrect, as harmful traditional practices are not encouraged anywhere. Choice C is incorrect as modern surgery and organizations like IRH aim to eliminate such practices, not recommend them. Choice D is incorrect as these practices are not related to safer sex practices but rather harmful practices that need to be eradicated.
4. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?
- A. Hold all bedtime medication.
- B. Keep the client NPO after midnight.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct answer: B
Rationale: Keeping the client NPO after midnight is essential to prevent aspiration during the ECT procedure. Choice A, holding all bedtime medication, is not necessary unless specified by the healthcare provider. Choice C, implementing elopement precautions, is unrelated to preparing for ECT. Choice D, giving the client an enema at bedtime, is not a standard pre-ECT intervention.
5. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?
- A. Install grab bars in the bathroom
- B. Provide a walker for ambulation
- C. Educate the client on fall prevention strategies
- D. Refer the client to a physical therapist
Correct answer: A
Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.