HESI LPN
HESI Maternity 55 Questions
1. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct answer: C
Rationale: A sodium level of 110 mEq/L is critically low and can indicate severe dehydration and electrolyte imbalance, requiring immediate intervention.
2. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?
- A. Apical heart rate
- B. IV site and fluids
- C. Pain scale
- D. Temperature
Correct answer: C
Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.
3. A client is being taught about the use of an incentive spirometer. Which statement by the client indicates effective teaching?
- A. I will use the spirometer every hour while awake.
- B. I will blow into the spirometer as hard as I can.
- C. I should feel dizzy when using the spirometer.
- D. I will only use the spirometer if I feel short of breath.
Correct answer: A
Rationale: The correct answer is A because using the spirometer every hour while awake is an effective way to prevent respiratory complications. This frequency helps in maintaining lung function and preventing atelectasis. Choice B is incorrect because blowing too hard into the spirometer can lead to hyperventilation and dizziness, making choice C also incorrect. Choice D is wrong as waiting to use the spirometer only when feeling short of breath may not provide optimal lung expansion and can lead to respiratory issues.
4. When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
5. A nurse is assessing a child with suspected rotavirus infection. What clinical manifestation is the nurse likely to observe?
- A. Abdominal pain
- B. Diarrhea
- C. Constipation
- D. Vomiting
Correct answer: B
Rationale: The correct answer is B: Diarrhea. Rotavirus infection commonly presents with symptoms such as watery diarrhea, vomiting, fever, and abdominal pain. While abdominal pain and vomiting are also associated with rotavirus infection, diarrhea is a hallmark feature. Constipation is not typically seen in cases of rotavirus infection. Therefore, the most likely clinical manifestation that the nurse would observe in a child with suspected rotavirus infection is diarrhea.