HESI LPN
Medical Surgical HESI
1. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?
- A. Increase your intake of potassium-rich foods.
- B. Restrict your fluid intake to 1 liter per day.
- C. Avoid salt substitutes containing potassium.
- D. Weigh yourself once a week.
Correct answer: A
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.
2. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?
- A. Thread the IV catheter so that the hub rests at the insertion site
- B. Shave excess hair from around the insertion site
- C. Cleanse the site with hydrogen peroxide before IV catheter insertion
- D. Palpate the site carefully just before inserting the IV catheter
Correct answer: A
Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.
3. A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform a further assessment because it may indicate inadequate oxygenation or circulation, potentially related to cardiac or respiratory issues. Flat occiput (choice A) is a common finding in infants and is not typically concerning. Small, low-set ears (choice B) are common in Down syndrome and not specifically indicative of an acute issue requiring immediate further assessment. Protruding furrowed tongue (choice D) is also commonly seen in infants with Down syndrome and typically does not warrant immediate further assessment unless associated with other concerning signs or symptoms.
4. To prevent keratitis in an unconscious client, where should the nurse apply moisturizing ointment?
- A. Finger and toenail quicks
- B. Eyes
- C. Perianal area
- D. External ear canals
Correct answer: B
Rationale: The correct answer is B: Eyes. Applying moisturizing ointment to the eyes helps prevent keratitis, a condition that can occur due to inadequate blinking in unconscious clients, leading to corneal dryness and potential damage. Choices A, C, and D are incorrect as moisturizing ointment should not be applied to finger and toenail quicks, perianal area, or external ear canals to prevent keratitis.
5. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?
- A. Avoid standing up too quickly.
- B. Increase fluid intake to stay hydrated.
- C. Eat more salt to help retain fluids.
- D. Wear compression stockings during the day.
Correct answer: A
Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.