HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
- A. Determine what IV medications have recently been administered.
- B. Slow the infusion rate.
- C. Apply a warm compress to the IV site.
- D. Discontinue the IV line and start a new one.
Correct answer: A
Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.
2. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?
- A. Contact the pharmacy and request the prescribed form of aspirin
- B. Instruct the client about the effects of the medication
- C. Administer the aspirin with a full glass of water or a small snack
- D. Withhold the aspirin until consulting with the healthcare provider
Correct answer: A
Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation. Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.
3. You assisted the midwife in formulating the objectives of the plan of care for Barangay Mabulaklak. Which of the following is a well-stated objective?
- A. to reduce the number of children with ascariasis by the end of two years
- B. to protect the water sources from pollution
- C. to conduct health teachings on proper nutrition
- D. to reduce the number of underweight children by 10%
Correct answer: D
Rationale: A specific, measurable objective like reducing the number of underweight children by 10% is well-stated. This objective is clear, quantifiable, and time-bound, making it easier to track progress and evaluate the effectiveness of the plan. Choices A, B, and C are not as well-stated as they lack specificity, measurability, and a quantifiable target.
4. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?
- A. Administer a prescribed PRN antianxiety medication.
- B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
- C. Allow time for the ritualistic behavior, then redirect the client to other activities.
- D. Teach the client relaxation and thought-stopping techniques.
Correct answer: C
Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.
5. In evaluating your client's level of wellness, which of the following indicators can you see?
- A. Appropriate nutritional level
- B. Sense of personal security
- C. Acceptance of oneself and one's limitations
- D. Maladaptations to one's environment
Correct answer: C
Rationale: When evaluating a client's level of wellness, indicators such as appropriate nutritional level, sense of personal security, and acceptance of oneself and one's limitations are crucial. Option C, 'Acceptance of oneself and one's limitations,' directly relates to mental wellness and self-awareness, making it a key indicator of overall well-being. Options A, B, and D are not as directly tied to the psychological and emotional aspects of wellness, making them less relevant indicators in this context. Therefore, the correct answer is C.