HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. Recurrent abdominal pain (RAP) is most often seen in school-age or adolescent children. The nurse should assess closely for what potential problem?
- A. Physical problems
- B. Relational problems
- C. Eating disorders
- D. Emotional problems
Correct answer: D
Rationale: The correct answer is D: 'Emotional problems.' Recurrent abdominal pain (RAP) in children is frequently associated with emotional factors rather than physical issues, relational problems, or eating disorders. Children may manifest emotional distress through physical symptoms like abdominal pain, making it crucial for nurses to assess for emotional problems as a potential cause.
2. Based on this strip, what is the correct interpretation of this rhythm?
- A. Atrial fibrillation.
- B. Premature atrial fibrillation.
- C. AV block.
- D. Ventricular tachycardia.
Correct answer: A
Rationale: The correct interpretation of the rhythm strip is atrial fibrillation. This arrhythmia is characterized by an irregular heartbeat and the absence of distinct P waves. Choice B, premature atrial fibrillation, is incorrect as there is no indication of premature beats in the strip. Choice C, AV block, is also incorrect as there is no evidence of conduction delays between the atria and ventricles. Choice D, ventricular tachycardia, is not supported by the absence of wide QRS complexes typically seen in this arrhythmia.
3. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
- A. Inflammation of the vessels
- B. Obstructed blood flow
- C. Overhydration
- D. Stress-related headaches
Correct answer: B
Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.
4. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?
- A. Increase your intake of potassium-rich foods.
- B. Restrict your fluid intake to 1 liter per day.
- C. Avoid salt substitutes containing potassium.
- D. Weigh yourself once a week.
Correct answer: A
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.
5. 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.
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