HESI LPN
Maternity HESI Test Bank
1. A nurse is planning to teach a group of clients who are breastfeeding after returning to work. Which of the following instructions should the nurse include in the teaching?
- A. “Thawed breast milk can be refrigerated for up to 24 hours.”
- B. “Breast milk can be stored in a deep freezer for 12 months.”
- C. “Breast milk can be stored at room temperature for up to 4 hours.”
- D. “Thawed breast milk that is unused cannot be refrozen.”
Correct answer: B
Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This instruction is important for mothers returning to work to ensure a long-term storage option for breast milk. Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator. Choice C is incorrect as breast milk can be kept at room temperature for only up to 4 hours. Choice D is incorrect as thawed breast milk that is unused should not be refrozen due to safety concerns.
2. A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?
- A. Moon face, slow wound healing, muscle wasting, sodium and water retention
- B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
- C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
- D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
Correct answer: A
Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.
3. What is the primary role of dietary guidelines?
- A. To ensure that all food groups are consumed in appropriate proportions.
- B. To prevent chronic diseases and promote overall well-being.
- C. To help individuals meet their nutritional needs while reducing the risk of chronic disease.
- D. To offer specific recommendations for the intake of nutrients that support health.
Correct answer: C
Rationale: The correct answer is C: 'To help individuals meet their nutritional needs while reducing the risk of chronic disease.' Dietary guidelines are designed to provide guidance on the types and amounts of food that support good health and reduce the risk of chronic diseases. Choice A has been corrected to mention 'appropriate proportions' instead of 'equal amounts,' as dietary guidelines emphasize balance and variety. Choice B is partially correct, but the primary focus of dietary guidelines is on meeting nutritional needs. Choice D is incorrect because while dietary guidelines may include nutrient recommendations, their primary focus is on overall dietary patterns rather than specific nutrient intake.
4. The parents of a child with sickle cell anemia ask why their child experiences pain. What is the most likely cause?
- A. Inflammation of the vessels
- B. Obstructed blood flow
- C. Overhydration
- D. Stress-related headaches
Correct answer: B
Rationale: In sickle cell anemia, pain is primarily caused by the obstruction of blood flow by sickle-shaped cells. This obstruction leads to inadequate oxygen supply to tissues, resulting in tissue damage and pain. Choice A, inflammation of the vessels, is incorrect as it is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia and would not lead to the characteristic pain experienced. Choice D, stress-related headaches, is also unrelated to the underlying mechanisms of pain in sickle cell anemia.
5. A cerebrovascular accident patient is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates no extraordinary life-saving measures. What action should the nurse take?
- A. Refer to the risk manager
- B. Notify the healthcare provider
- C. Discontinue the ventilator
- D. Review the medical record
Correct answer: B
Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.