HESI LPN
Medical Surgical Assignment Exam HESI
1. A male client with diabetes mellitus is transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement?
- A. Provide a warming pad for his feet
- B. Medicate the client with a prescribed sedative.
- C. Use a bed cradle to keep the covers off his feet.
- D. Place warm blankets next to the client's feet.
Correct answer: D
Rationale: Placing warm blankets next to the client's feet is the most appropriate action to provide warmth and comfort. This method is safe and effective in addressing the client's complaint of uncomfortably cool feet at night. Providing a warming pad (Choice A) may pose a risk of burns or injury, especially for a client with decreased sensation due to diabetes. Mediating the client with a sedative (Choice B) does not address the underlying issue of cool feet and may not be necessary. Using a bed cradle (Choice C) to hold the covers off the feet does not directly address the client's need for warmth and comfort.
2. The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
3. 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.
4. The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
- A. Morning headaches
- B. Pain for 3 consecutive months
- C. Febrile episodes in the late afternoon
- D. Diaphoresis when attacks occur
Correct answer: B
Rationale: The correct answer is B: Pain for 3 consecutive months. Recurrent abdominal pain (RAP) is characterized by abdominal pain that occurs at least once per week for at least 2 months before diagnosis. Choosing option A is incorrect since morning headaches are not a common characteristic of RAP. Option C is incorrect because febrile episodes in the late afternoon are not typically associated with RAP. Option D is incorrect as diaphoresis (excessive sweating) when attacks occur is not a common finding in RAP.
5. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?
- A. Apical pulse 58 bpm.
- B. Core body temperature 100.8°F.
- C. Tachypnea with dyspnea.
- D. Multiple bruises over the chest area.
Correct answer: C
Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI LPN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access