HESI LPN
Medical Surgical HESI 2023
1. A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.
2. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?
- A. Administer acetylcysteine (Mucomyst).
- B. Monitor cardiac rhythm for flat T waves.
- C. Check both serum AST and ALT levels.
- D. Prepare to administer Syrup of Ipecac.
Correct answer: A
Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.
3. What title should be given to this occupational health nurse job description?
- A. manager
- B. case manager
- C. health educator
- D. nurse consultant
Correct answer: D
Rationale: The correct title for this occupational health nurse job description is 'nurse consultant.' A nurse consultant is a registered professional nurse with expertise in occupational and environmental health nursing, effective communication skills, and good administrative and consultative abilities. Choice A, 'manager,' is incorrect as the job description does not primarily focus on managerial duties. Choice B, 'case manager,' is incorrect as it does not fully cover the scope of the described role. Choice C, 'health educator,' is incorrect as it does not encompass the administrative and consultative skills mentioned in the job description.
4. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?
- A. Capillary refill takes > 3 seconds.
- B. Episodes of vertigo and loss of balance.
- C. Average daily output of 1200 ml.
- D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct answer: D
Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.
5. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?
- A. Allow the head to deliver and check for the location of the cord.
- B. Advise your partner to stop the ambulance and assist with the delivery.
- C. Tell the mother to take short, quick breaths until you arrive at the hospital.
- D. Prepare the mother for an emergency delivery and open the obstetrics kit.
Correct answer: B
Rationale: In this scenario, the most appropriate first action is to advise your partner to stop the ambulance and assist with the delivery. When the baby's head is visible and delivery is imminent, it is crucial to provide immediate assistance to ensure the safety of both the mother and the baby. Allowing the head to deliver and checking for the location of the cord (Choice A) may delay necessary actions during an imminent delivery. Instructing the mother to take short, quick breaths (Choice C) is not suitable as active delivery is already in progress. Preparing the mother for an emergency delivery and opening the obstetrics kit (Choice D) is not the most immediate action needed when the baby's head is already visible and delivery is imminent.