HESI LPN
HESI Test Bank Medical Surgical Nursing
1. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
- A. Alcohol
- B. Mineral oil
- C. Calamine
- D. A&D ointment
Correct answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
2. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the brace
- D. Spending a majority of their time with her
Correct answer: C
Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.
3. A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the teaching plan?
- A. Avoid taking folic acid supplements
- B. Report any signs of infection immediately
- C. Limit fluid intake to prevent edema
- D. Increase intake of high-calcium foods
Correct answer: B
Rationale: The correct instruction that the nurse should include in the teaching plan for a client prescribed methotrexate is to report any signs of infection immediately. Methotrexate can suppress the immune system, making the individual more susceptible to infections. Reporting signs of infection promptly allows for timely intervention. Choices A, C, and D are incorrect. Avoiding folic acid supplements is not recommended because methotrexate can lead to folate deficiency, so supplementation may be necessary. There is no direct correlation between fluid intake limitation and methotrexate use. Increasing high-calcium foods is not specifically related to methotrexate therapy for rheumatoid arthritis.
4. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?
- A. Leaving the lesion uncovered and placing the infant supine
- B. Covering the lesion with a sterile, saline-soaked gauze
- C. Applying lotion to the lesion to keep it moist
- D. Covering the lesion with a dry, sterile gauze
Correct answer: B
Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.
5. Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?
- A. Encourage the client to use an abductor pillow when ambulating.
- B. Teach the client to perform leg exercises in bed.
- C. Assist the client to sit at the edge of the bed.
- D. Assist the client to turn while an abductor pillow is between the legs.
Correct answer: D
Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.
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