HESI LPN
HESI Maternal Newborn
1. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage.
- B. Apply counterpressure to the client's sacrum.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct answer: B
Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.
2. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?
- A. 0.75 mL
- B. 1 mL
- C. 0.8 mL
- D. 1.2 mL
Correct answer: C
Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.
3. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
4. A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?
- A. Basic
- B. Commitment
- C. Complex
- D. Integrity
Correct answer: C
Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.
5. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?
- A. Risk for aspiration
- B. Impaired physical mobility
- C. Disturbed sensory perception
- D. Interrupted family processes
Correct answer: A
Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.