HESI LPN
Medical Surgical Assignment Exam HESI
1. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in LOC
Correct answer: D
Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.
2. As a supervisor, you plan to conduct a seminar in response to the midwife's training need for skills in community diagnosis. Which is an appropriate method to use to enable midwives to apply the knowledge they will gain in actual practice?
- A. lecture
- B. problem-solving
- C. group discussion
- D. nominal group technique
Correct answer: B
Rationale: Problem-solving is an effective method to enable midwives to apply the knowledge gained in actual practice. By engaging in problem-solving activities during the seminar, midwives can enhance their critical thinking skills and directly apply the information to real-life scenarios they may encounter in community diagnosis. Choice A (lecture) is less effective as it primarily involves passive listening and may not provide the hands-on experience needed for practical application. Choice C (group discussion) can be helpful for sharing perspectives but may not directly translate to practical application as problem-solving would. Choice D (nominal group technique) focuses more on generating ideas and reaching consensus rather than hands-on application of knowledge.
3. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?
- A. Administer nitroglycerin sublingually.
- B. Obtain a 12-lead ECG.
- C. Measure the client's vital signs.
- D. Administer oxygen via nasal cannula.
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.
4. Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct answer: D
Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.
5. A client with a diagnosis of generalized anxiety disorder is prescribed escitalopram. The nurse should instruct the client that this medication may have which potential side effect?
- A. Drowsiness
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: The correct potential side effect of escitalopram is drowsiness. Escitalopram is known to cause sedation, so clients should be advised to avoid activities that require mental alertness, such as driving, until they know how the medication affects them. Dry mouth, nausea, and headache are also common side effects of various medications but are not specifically associated with escitalopram.