HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client who had surgery yesterday is becoming increasingly anxious. The client’s respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum pH. Which serum laboratory value should the nurse monitor first?
- A. Electrolytes.
- B. Creatinine.
- C. Blood urea nitrogen.
- D. Glucose.
Correct answer: A
Rationale: The correct answer is A, Electrolytes. In this scenario, the client is at risk for metabolic alkalosis due to the loss of gastric secretions through the nasogastric tube. Monitoring electrolytes is crucial to assess the levels of sodium, potassium, chloride, and bicarbonate, which are important in maintaining the acid-base balance of the body. Changes in these electrolyte levels can provide valuable information about the client's fluid status and acid-base balance. Creatinine, blood urea nitrogen, and glucose levels are important parameters to monitor in different situations but are not the priority in this case of potential metabolic alkalosis.
2. A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take?
- A. Explain the importance of regular dressing changes
- B. Administer an anti-anxiety medication
- C. Proceed with the scheduled dressing change
- D. Encourage the client to express any anxieties
Correct answer: A
Rationale: In this situation, the most important action for the nurse to take is to explain the importance of regular dressing changes to the client. By doing so, the nurse can help the client understand the necessity for wound healing and infection prevention. Administering anti-anxiety medication (Choice B) may not address the root cause of the client's anxiety, which is the lack of understanding. Proceeding with the scheduled dressing change (Choice C) without addressing the client's concerns can worsen their anxiety and decrease trust. Encouraging the client to express any anxieties (Choice D) is important but not as crucial as ensuring the client comprehends the rationale behind the dressing change.
3. How should a healthcare provider address the nutritional needs of a child with chronic kidney disease?
- A. Increase protein intake
- B. Reduce sodium and phosphorus intake
- C. Promote a high-fat diet
- D. Encourage frequent sugary snacks
Correct answer: B
Rationale: Reducing sodium and phosphorus intake is crucial in managing chronic kidney disease in children because it helps prevent complications such as electrolyte imbalances and bone problems. High protein intake can actually be harmful to the kidneys in this condition as it can lead to increased waste production. A high-fat diet is not recommended as it can contribute to heart and blood vessel problems. Encouraging frequent sugary snacks can lead to further complications like obesity and diabetes, which are not beneficial for a child with chronic kidney disease.
4. A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?
- A. Morning sickness.
- B. Breast tenderness.
- C. Amenorrhea.
- D. Hegar's sign.
Correct answer: D
Rationale: Hegar's sign, which is a softening of the lower uterine segment, is considered a probable sign of pregnancy as it indicates changes in the cervix and uterus that occur during pregnancy. Amenorrhea, the absence of menstruation, is a common early sign of pregnancy but can also be due to other factors. Morning sickness, nausea and vomiting, can be a sign of early pregnancy but is not as specific as Hegar's sign. Breast tenderness is a common symptom in early pregnancy due to hormonal changes, but it is not as definitive as Hegar's sign in indicating pregnancy.
5. An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
- A. Determine what IV medications have recently been administered.
- B. Slow the infusion rate.
- C. Apply a warm compress to the IV site.
- D. Discontinue the IV line and start a new one.
Correct answer: A
Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.