HESI LPN
HESI Fundamentals 2023 Quizlet
1. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?
- A. In the morning upon rising.
- B. Immediately after the client eats breakfast.
- C. Before the client goes to bed.
- D. After the client has had a drink of water.
Correct answer: A
Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.
2. A client with preeclampsia is receiving magnesium sulfate by continuous IV infusion. Which finding should the nurse report to the provider?
- A. Blood pressure 148/94 mm Hg
- B. Respiratory rate 14/min
- C. Urinary output 20 mL/hr
- D. 2+ deep tendon reflexes
Correct answer: C
Rationale: In a client with preeclampsia receiving magnesium sulfate, a urinary output of 20 mL/hr is a concerning finding as it may indicate renal impairment or magnesium toxicity. Adequate urinary output is crucial for eliminating excess magnesium and preventing toxicity. The nurse should report this finding to the provider for further evaluation. A blood pressure of 148/94 mm Hg is elevated but expected in a client with preeclampsia. A respiratory rate of 14/min is within the normal range. 2+ deep tendon reflexes are a common finding in clients receiving magnesium sulfate and are not a cause for concern unless they progress to hyperreflexia or clonus.
3. A nurse in the emergency department observes large welts and scars on the back of a child who has been admitted for an asthma attack. What additional information must be included in the nurse’s assessment?
- A. History of an injury
- B. Signs of child abuse
- C. Presence of food allergies
- D. Recent recovery from chickenpox
Correct answer: B
Rationale: The correct answer is B: Signs of child abuse. Large welts and scars on a child may be indicative of abuse, making it crucial for the nurse to assess and report any suspicions. Assessing the history of an injury (choice A) may not provide insight into the cause of the welts and scars as effectively as looking for signs of potential abuse. Food allergies (choice C) and recent recovery from chickenpox (choice D) are not directly relevant to the observation of welts and scars on the child's back.
4. What finding would lead the nurse to suspect that a child has Turner syndrome?
- A. Webbed neck
- B. Microcephaly
- C. Gynecomastia
- D. Cognitive delay
Correct answer: A
Rationale: A webbed neck is a key feature seen in Turner syndrome, a genetic condition that occurs in females due to a complete or partial absence of one of the X chromosomes. This physical trait is caused by excess skin on the neck, giving it a webbed appearance. Microcephaly (Choice B) is a condition characterized by a smaller than average head size and is not typically associated with Turner syndrome. Gynecomastia (Choice C) refers to breast enlargement in males and is not a common finding in Turner syndrome, which affects females. Cognitive delay (Choice D) is not a specific characteristic of Turner syndrome, as the syndrome primarily affects physical development and may not necessarily impact cognitive abilities.
5. Which of the following signs or symptoms is more common in children than adults following head trauma?
- A. nausea and vomiting
- B. altered mental status
- C. tachycardia and diaphoresis
- D. changes in pupillary reaction
Correct answer: A
Rationale: Nausea and vomiting are more common in children following head trauma due to their higher risk of increased intracranial pressure. Children have less space for swelling within the skull compared to adults, making them more prone to experiencing symptoms like nausea and vomiting. Altered mental status and changes in pupillary reaction can also occur in both children and adults following head trauma, but they are not specifically more common in children. Tachycardia and diaphoresis are generally signs of autonomic nervous system activation and may occur in both children and adults, but they are not typically more common in children compared to adults following head trauma.