HESI LPN
Medical Surgical HESI
1. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. Which intervention should the nurse implement?
- A. Administer a prescribed sedative
- B. Encourage client to drink water
- C. Apply a high flow venturi mask
- D. Assist her to an upright position
Correct answer: D
Rationale: Assisting the client to an upright position is the most appropriate intervention in this situation. Placing the client upright helps improve lung expansion by reducing diaphragmatic pressure, facilitating better air exchange, and increasing oxygenation. This position also aids in easing breathing efforts. Administering a sedative (Choice A) may further depress the respiratory system, worsening the breathing problem. Encouraging the client to drink water (Choice B) may not directly address the respiratory distress caused by COPD. Applying a high flow venturi mask (Choice C) may be beneficial in some cases but assisting the client to an upright position should be the priority to optimize respiratory function.
2. How should the nurse manage a child with acute lymphoblastic leukemia (ALL) who is receiving chemotherapy?
- A. Avoid all physical activity
- B. Ensure strict infection control measures
- C. Increase daily caloric intake
- D. Limit fluid intake
Correct answer: B
Rationale: The correct answer is B: Ensure strict infection control measures. Children with acute lymphoblastic leukemia (ALL) who are undergoing chemotherapy have compromised immune systems, making them highly susceptible to infections. Implementing strict infection control measures, such as hand hygiene, limiting exposure to sick individuals, and maintaining a clean environment, is essential to prevent infections. Choice A is incorrect because avoiding all physical activity may not be necessary as long as the child's activity level is appropriate. Choice C is incorrect because increasing daily caloric intake is important to support the child's nutritional needs during treatment. Choice D is incorrect because limiting fluid intake is not typically recommended unless specifically advised by the healthcare provider.
3. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
4. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?
- A. The goals set by the client
- B. The learning level of the client
- C. Assessing the home environment
- D. The distractions in the client's home
Correct answer: C
Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.
5. A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant’s discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?
- A. It should not be given until the infant reaches 2 years of age.
- B. Infants who are receiving chemotherapy should not be given these vaccines.
- C. It should be given to protect the infant from contracting any of these diseases.
- D. The parents should discuss this with their healthcare provider at the next visit.
Correct answer: B
Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.