HESI LPN
Leadership and Management HESI Quizlet
1. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage VI
Correct answer: B
Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.
2. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?
- A. Recheck the radial pulse in thirty minutes
- B. Palpate the radial pulse for thirty seconds and double the rate
- C. Count the apical pulse rate for sixty seconds
- D. Compare the radial pulse rate bilaterally and record the higher rate
Correct answer: C
Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.
3. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?
- A. “Tell me about your daily routine.”
- B. “You look tired. Is everything alright?”
- C. “When was the last time the baby had a bottle?”
- D. “Oh, it looks like you two are having a bad day.”
Correct answer: A
Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.
4. A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring fluid and electrolyte balance
- B. Encouraging regular exercise
- C. Administering antipyretics
- D. Administering antibiotics
Correct answer: A
Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract, leading to fluid loss. Maintaining fluid and electrolyte balance is essential in managing gastroenteritis to prevent dehydration and electrolyte imbalances. Encouraging regular exercise (Choice B) is not a priority in the acute phase of gastroenteritis when the focus is on rehydration and symptom management. Administering antipyretics (Choice C) may be considered for fever management but is not the priority over monitoring fluid and electrolyte balance. Administering antibiotics (Choice D) is not routinely indicated for viral gastroenteritis, which is a common cause of the condition in children.
5. A client with hypertension is prescribed lisinopril. The nurse should monitor for which potential side effect?
- A. Dry cough
- B. Hyperkalemia
- C. Hypernatremia
- D. Hyponatremia
Correct answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril, an ACE inhibitor, is known to cause a persistent dry cough as a common side effect. Monitoring for this adverse effect is crucial because it may lead to non-adherence to the medication. Hyperkalemia (choice B) is a potential side effect of potassium-sparing diuretics, not ACE inhibitors like lisinopril. Hypernatremia (choice C) refers to elevated sodium levels and is not a common side effect of lisinopril. Hyponatremia (choice D) is a condition characterized by low sodium levels and is not a typical side effect of lisinopril. Therefore, the nurse should focus on assessing the client for a dry cough when taking lisinopril.