HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?
- A. Ensure patency of an indwelling catheter and measure hourly intake and output.
- B. Prepare for cessation of the anesthesia and the surgical procedure.
- C. Obtain specimens of ABGs and serum electrolytes.
- D. Initiate cooling measures using iced normal saline by nasogastric lavage.
Correct answer: B
Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.
2. The nurse is teaching a client about coronary artery disease (CAD) preventive health. Which behavior stated by the client indicates a need for additional information and teaching?
- A. Increasing physical activity.
- B. Eating a low-fat diet.
- C. Decreasing the number of cigarettes smoked per day.
- D. Monitoring blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Decreasing the number of cigarettes smoked per day is not sufficient for CAD prevention. Smoking cessation is crucial in reducing the risk of CAD. While increasing physical activity, eating a low-fat diet, and monitoring blood pressure regularly are all positive behaviors for CAD prevention, quitting smoking should be emphasized due to its significant impact on cardiovascular health.
3. 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.
4. The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?
- A. Applesauce
- B. White rice
- C. Coffee
- D. Bananas
Correct answer: C
Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.
5. What could suddenly occur in a child with acute epiglottitis?
- A. Increased carbon dioxide levels
- B. Airway obstruction
- C. Inability to swallow
- D. Bronchial collapse
Correct answer: B
Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.
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