HESI LPN
Medical Surgical HESI
1. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?
- A. Assist with personal care, but leave oral care for the nurse to complete.
- B. Provide a soft bristle brush for the client to use during oral care.
- C. Use alcohol-based mouthwash to clean the ulcers.
- D. Apply an antifungal cream to the mouth ulcers.
Correct answer: B
Rationale: The correct answer is B: 'Provide a soft bristle brush for the client to use during oral care.' Providing a soft bristle brush helps reduce trauma to the oral mucosa and assists in oral care. Choice A is incorrect because oral care can be safely delegated to UAPs. Choice C is wrong as alcohol-based mouthwash can further irritate the ulcers. Choice D is incorrect as applying an antifungal cream directly to the mouth ulcers is not the standard treatment for oral candidiasis.
2. A client with schizophrenia who has been stabilized on medication is being discharged from the hospital. What discharge teaching is most important for the LPN/LVN to reinforce?
- A. The importance of adhering to the prescribed medication regimen.
- B. How to recognize early signs of relapse.
- C. The need to continue follow-up appointments with the healthcare provider.
- D. The importance of maintaining a healthy lifestyle, including proper diet and exercise.
Correct answer: A
Rationale: The correct answer is A. Reinforcing the importance of adhering to the prescribed medication regimen is crucial for preventing relapse in clients with schizophrenia. Compliance with medication is essential in managing the symptoms and preventing a worsening of the condition. Choice B, recognizing early signs of relapse, is important but secondary to ensuring medication adherence. Choice C, follow-up appointments, is also important but not as critical as medication compliance immediately post-discharge. Choice D, maintaining a healthy lifestyle, is beneficial for overall health but is not as directly linked to preventing relapse in schizophrenia as medication adherence.
3. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?
- A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
- B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
- C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
- D. Record the findings on the chart. They are within normal limits.
Correct answer: D
Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.
4. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct answer: C
Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.
5. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- A. Wear cotton clothing to avoid static electricity.
- B. Avoid using any electrical appliances.
- C. Keep the oxygen tank away from heat sources.
- D. Use only a specific type of nasal cannula.
Correct answer: A
Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.