HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter-sized blood spot on the dressing
- D. Pitting ankle edema
Correct answer: A
Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.
2. Your friend Carrie took a daily supplement of vitamin C and tells you that she feels a lot better. Her statement to you is best described as what?
- A. an anecdote
- B. theory
- C. interpretation
- D. conclusion
Correct answer: A
Rationale: The correct answer is A, 'an anecdote.' An anecdote is a personal account or experience, not necessarily backed by scientific evidence. In this case, Carrie's statement about feeling better after taking vitamin C is based on her personal experience and does not constitute scientific evidence or a generalizable conclusion. Choice B, 'theory,' would imply a systematic explanation based on scientific evidence, which is not the case here. Choice C, 'interpretation,' typically involves explaining or understanding something based on available information, not a personal account. Choice D, 'conclusion,' would be a general statement derived from specific information or facts, which is not applicable in this context.
3. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
- A. Every 4 to 8 hours
- B. Every 12 to 24 hours
- C. Every 24 to 48 hours
- D. Every 72 to 96 hours
Correct answer: D
Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.
4. Tertiary prevention would best be described as:
- A. recovery from physical limitation and psychological regression
- B. health teaching and immunization
- C. rehabilitation of alcoholic and drug dependents
- D. preventing disability and maximum use of remaining capacity
Correct answer: D
Rationale: Tertiary prevention is the stage of prevention that aims at preventing disability and maximizing the use of remaining capacity. Choice A is more aligned with rehabilitation rather than tertiary prevention. Choice B refers to primary prevention by promoting health and preventing diseases. Choice C focuses on rehabilitation specific to alcohol and drug dependence, which is a form of secondary prevention, not tertiary prevention.
5. The nurse is caring for a 3-day-old girl with Down syndrome whose mother had no prenatal care. What is the priority nursing diagnosis?
- A. Imbalanced nutrition, less than body requirements related to the effects of hypotonia
- B. Deficient knowledge related to the presence of a genetic disorder
- C. Delayed growth and development related to cognitive impairment
- D. Impaired physical mobility related to poor muscle tone
Correct answer: A
Rationale: The priority nursing diagnosis for a newborn with Down syndrome is often related to feeding difficulties due to hypotonia, making imbalanced nutrition the primary concern. Hypotonia, or poor muscle tone, can lead to challenges with feeding and, subsequently, affect the baby's nutritional intake. While choices B, C, and D may also be concerns for a child with Down syndrome, addressing the immediate need for adequate nutrition takes precedence to ensure the infant's well-being and growth.