HESI LPN
Medical Surgical HESI 2023
1. A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Increase oxygen flow rate during physical activity
- B. Smoke at least 10 feet away from the oxygen source
- C. Use petroleum jelly to prevent nasal dryness
- D. Ensure the oxygen tank is stored in a secure upright position
Correct answer: D
Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.
2. The home health nursing director is conducting an educational program for registered nurses and practical nurses about Medicare reimbursement. To obtain payment for Medicare services, what must be included in the client's record?
- A. A prescription from the healthcare provider for each visit made.
- B. Documentation of a skilled care service provided during the visit.
- C. A copy of the client's health history and social security card.
- D. A record of the preventative healthcare services provided during the visit.
Correct answer: B
Rationale: The correct answer is B: Documentation of skilled care services is required for Medicare reimbursement. Medicare reimbursement is based on the provision of skilled care services, not on prescriptions or preventative healthcare services. Including a copy of the client's health history and social security card is not a requirement for Medicare reimbursement.
3. A client with chronic renal failure is receiving peritoneal dialysis. The nurse should assess the client for which of the following complications?
- A. Hypertension
- B. Hyperglycemia
- C. Hypokalemia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hyperglycemia. In peritoneal dialysis, hyperglycemia can occur due to the glucose content of the dialysate solution. This high glucose concentration can lead to increased blood sugar levels in the client. Option A, Hypertension, is a common complication in chronic renal failure but is not directly related to peritoneal dialysis. Option C, Hypokalemia, is more commonly associated with loop diuretics or inadequate potassium intake. Option D, Hypernatremia, is more often seen in conditions of excessive sodium intake or water loss, rather than in peritoneal dialysis.
4. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?
- A. Breathe deeply, followed by swallowing.
- B. Breathe deeply, followed by spitting into a cup.
- C. Breathe deeply, followed by coughing up the sputum.
- D. Breathe deeply, followed by clearing the throat.
Correct answer: C
Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.
5. Which signs/symptoms would be considered classical signs of meningeal irritation?
- A. Positive Kernig sign, diarrhea, and headache
- B. Negative Brudzinski sign, positive Kernig sign, and irritability
- C. Positive Brudzinski sign, positive Kernig sign, and photophobia
- D. Negative Kernig sign, vomiting, and fever
Correct answer: C
Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.