HESI LPN
Medical Surgical HESI 2023
1. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
- A. Two liters.
- B. Three liters.
- C. Four liters.
- D. Five liters.
Correct answer: B
Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.
2. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take?
- A. Make a copy of the incident report for personal records
- B. Identify the medication name and dosage administered to the client in the report
- C. Obtain an order from the client's provider to complete the report
- D. Include the time the medication error occurred in the report
Correct answer: B
Rationale: The correct answer is to identify the medication name and dosage administered to the client in the incident report. This information is crucial for accurate documentation and investigation of the medication error. Choice A is incorrect because incident reports are usually kept confidential and not for personal keeping. Choice C is incorrect as obtaining an order from the client's provider is not necessary to complete an incident report. Choice D, while important, is not the only essential information needed for the incident report.
3. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct answer: B
Rationale: Assessing for impaction is crucial as it is a common cause of constipation and abdominal discomfort. In this scenario, the patient's symptoms of chronic constipation and no bowel movement for five days despite trying home remedies indicate a potential impaction that needs to be assessed. Evaluating stool samples for blood, determining the home remedies used, or obtaining a list of prescribed medications, while potentially relevant, are not as urgent as assessing for impaction in this situation.
4. A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?
- A. Sublimation
- B. Suppression
- C. Regression
- D. Compensation
Correct answer: A
Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.
5. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?
- A. Remove elastic stockings every 4 hours.
- B. Measure the calf circumference of both legs.
- C. Lightly rub the lower leg for redness and tenderness.
- D. Dorsiflex the foot while assessing for patient discomfort.
Correct answer: B
Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.