a nurse is auscultating the anterior chest wall of a client newly admitted to a medical surgical unit identify the type of breath sounds a nurse is auscultating the anterior chest wall of a client newly admitted to a medical surgical unit identify the type of breath sounds
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?

Correct answer: A

Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.

2. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?

Correct answer: A

Rationale: Dry mouth is a common side effect of MAO inhibitors like phenelzine due to their anticholinergic effects. Choices B, C, and D are incorrect as indigestion, diarrhea, and pink urine are not commonly associated side effects of phenelzine.

3. A child is admitted with extensive burns. The nurse notes burns on the child’s lips and singed nasal hairs. The nurse should suspect that the child has a(n)

Correct answer: B

Rationale: Burns on the lips and singed nasal hairs are indicative of an inhalation injury. This suggests that the child has likely inhaled hot gases or smoke, leading to damage in the respiratory tract. Choice A, chemical burn, is incorrect because the symptoms described are more aligned with inhalation rather than direct contact with chemicals. Choice C, electrical burn, is incorrect as there are no mentions of contact with an electrical source. Choice D, hot-water scald, is also incorrect as the presentation of burns on the lips and singed nasal hairs is not characteristic of scald injuries.

4. As a community organizer, the PHN facilitates the planning and implementation of program subjects in the community. In the light of the PHC approach, these programs/projects should be characterized by the following except:

Correct answer: B

Rationale: In the context of the PHC approach, programs should be characterized by being managed by community leaders/members (Choice A). This ensures community involvement and ownership. Programs should also be compatible with available resources (Choice C) to be sustainable and effective. Additionally, programs should be developmental in nature (Choice D), focusing on long-term improvements. Choice B is incorrect because programs should not be solely managed by non-government organizations; instead, they should be driven by the community to promote sustainability and empowerment.

5. A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?

Correct answer: D

Rationale: An evidence-based nursing journal is the correct choice for the nurse to obtain information about the prevalence of Tay-Sachs disease. These journals contain peer-reviewed research and studies conducted by experts in the field, providing accurate and reliable information. Choice A, the client's health care provider, may have general information but may not provide detailed prevalence data. Choice B, a collaborative, user-edited website, is not a reliable source as the information may be inaccurate or outdated. Choice C, the facility's case manager, is unlikely to have specific prevalence data on Tay-Sachs disease.

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