HESI LPN
Medical Surgical Assignment Exam HESI
1. A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?
- A. Encourage the client to eat quickly.
- B. Provide a straw for liquids.
- C. Place the client in an upright position during meals.
- D. Offer thin liquids.
Correct answer: C
Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.
2. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?
- A. Broccoli
- B. Chicken breast
- C. White bread
- D. Apple
Correct answer: A
Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.
3. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?
- A. Review the client's dietary intake of high protein foods
- B. Notify the healthcare provider of the finding immediately
- C. Discuss approaches to chronic pain control with the client
- D. Assess the client's radial pulses and capillary refill time
Correct answer: C
Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.
4. What is the most critical initial intervention for a client who is actively seizing?
- A. Restrain the client to prevent injury
- B. Insert an oral airway
- C. Turn the client to the side
- D. Apply soft restraints to the wrists
Correct answer: C
Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.
5. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
- A. Avoid coiling the tubing and keep it free of kinks.
- B. Cleanse the perineal area with soap and water twice daily.
- C. Keep the drainage bag lower than the level of the bladder.
- D. Drink 1,000 ml of fluids daily to irrigate the catheter.
Correct answer: C
Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.
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