HESI LPN
HESI Test Bank Medical Surgical Nursing
1. An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.
- A. Normal Saline
- B. Lactated Ringer’s
- C. 5% Dextrose in water
- D. 0.45% Sodium Chloride
Correct answer: B
Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.
2. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?
- A. Tie the restraint with a quick-release knot.
- B. Use a slipknot to secure the restraint.
- C. Ensure the restraint is tightly secured.
- D. Attach the restraint to the bed frame.
Correct answer: A
Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.
3. A client with chronic kidney disease is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. Decreased urine output
- B. Weight loss of 1 kg
- C. Blood pressure of 150/90 mm Hg
- D. Presence of a bruit over the fistula
Correct answer: C
Rationale: The correct answer is C. An elevated blood pressure in clients with chronic kidney disease undergoing hemodialysis can indicate fluid overload or poor dialysis efficacy and should be reported immediately. This finding could lead to complications such as heart failure or pulmonary edema. Choices A, B, and D are not as critical in this situation. Decreased urine output may be expected due to the kidney disease, a weight loss of 1 kg is within an acceptable range, and the presence of a bruit over the fistula is a common finding in clients undergoing hemodialysis and does not require immediate reporting.
4. A caregiver is talking with the caregivers of a 10-year-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the caregiver make?
- A. “Perhaps you should try to find out what is happening behind those closed doors.”
- B. “Suggest that the door be left ajar for safety reasons.”
- C. “At this age, children tend to become modest and value their privacy.”
- D. “You should establish a disciplinary plan to stop this behavior.”
Correct answer: C
Rationale: The correct response is C: “At this age, children tend to become modest and value their privacy.” During the developmental stage around 10 years old, children often start to value their privacy more and exhibit behaviors like closing doors when showering or dressing. It is a normal part of growing up and developing a sense of modesty. Choice A is incorrect as it suggests prying into the child's privacy, which may be counterproductive and invasive. Choice B is not the best response as it focuses on safety but fails to address the child's developmental stage and need for privacy. Choice D is also incorrect as it advocates for discipline without recognizing the normal developmental behavior of children at this age.
5. A healthcare provider is assessing a 2-year-old child with suspected Down syndrome. What characteristic physical feature is the healthcare provider likely to observe?
- A. Epicanthal folds
- B. Webbed neck
- C. Enlarged head
- D. Polydactyly
Correct answer: A
Rationale: Epicanthal folds are a common physical feature seen in individuals with Down syndrome. These are folds of skin that cover the inner corners of the eyes. Webbed neck (Choice B) is associated with Turner syndrome, not Down syndrome. Enlarged head (Choice C) is not a typical physical characteristic of Down syndrome. Polydactyly (Choice D) is the presence of extra fingers or toes, which is not specifically related to Down syndrome.