HESI LPN
Medical Surgical HESI
1. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until the color returns to normal
Correct answer: D
Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.
2. The increasing number of people who must learn to live with chronic illness in the community implies the need for the PHN to plan and implement a program on:
- A. communicable disease control
- B. health education
- C. child survival
- D. environmental education
Correct answer: B
Rationale: The correct answer is B: health education. Health education is crucial for individuals dealing with chronic illnesses as it helps them learn how to manage their conditions effectively. Communicable disease control (choice A) focuses on preventing the spread of infectious diseases, which is not directly related to managing chronic conditions. Child survival (choice C) pertains to initiatives aimed at reducing child mortality rates, which is not directly related to addressing chronic illnesses. Environmental education (choice D) involves raising awareness about environmental issues, which is also not directly related to helping individuals live with chronic illnesses.
3. When preparing the client for a thoracentesis, which action is essential for the nurse to take?
- A. Encourage the client to cough during the procedure
- B. Ask the client to void prior to the procedure
- C. Have the client lie in the prone position
- D. Determine if chest x-rays have been completed
Correct answer: B
Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.
4. A parent asks the nurse what to do when their toddler has temper tantrums. What play materials should the nurse suggest to offer the child as another way of expressing anger?
- A. Ball and bat
- B. Wad of clay
- C. Punching bag
- D. Pegs and pounding board
Correct answer: D
Rationale: Pegs and pounding boards are the most suitable choice for toddlers to express their emotions constructively. These materials provide a safe and acceptable way for toddlers to release anger and frustration through physical activity. Options A, B, and C may not be as effective or safe for toddlers dealing with temper tantrums. A ball and bat may encourage aggressive behavior rather than constructive expression. A wad of clay might not be ideal for channeling anger, and a punching bag can potentially promote violent behavior, which is not appropriate for toddlers.
5. What is an important aspect of the care plan for a child with eczema?
- A. Use of steroid creams
- B. Frequent antibiotic therapy
- C. High-protein diet
- D. Daily baths in hot water
Correct answer: A
Rationale: The correct answer is A: Use of steroid creams. Steroid creams are commonly used in the management of eczema to reduce inflammation and itching, thus improving the skin condition and comfort of the child. Choice B, frequent antibiotic therapy, is incorrect as antibiotics are not typically used to treat eczema unless there is a secondary bacterial infection. Choice C, a high-protein diet, is not a specific recommendation for eczema treatment. Choice D, daily baths in hot water, is not recommended for eczema care as hot water can exacerbate the condition by drying out the skin.