HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Processed cheese
- C. Whole grain bread
- D. Fresh vegetables
Correct answer: B
Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.
2. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)
- A. Verify pedal pulses using a doppler pulse device.
- B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
- C. Evaluate the application of the splint to the left leg.
- D.
Correct answer: C
Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.
3. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?
- A. Flush the tube with 50 mL of normal saline every 8 hours
- B. Clamp the tube when not in use
- C. Position the client in a supine position
- D. Verify tube placement by checking pH of gastric contents
Correct answer: D
Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.
4. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)
- A. Monitor electrolyte levels.
- B. Maintain pulse oximetry.
- C. Provide assistance with mobility.
- D. All of the Above
Correct answer: D
Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.
5. Which individual has the highest risk for developing skin cancer?
- A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
- B. A 65-year-old fair-skinned male who is a construction worker
- C. A 25-year-old dark-skinned male whose mother had skin cancer.
- D. A 70-year-old fair-skinned female who works as a secretary.
Correct answer: B
Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.
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