HESI RN
HESI Maternity Test Bank
1. When should the LPN/LVN encourage the laboring client to begin pushing?
- A. When there is only an anterior or posterior lip of the cervix left.
- B. When the client describes the need to have a bowel movement.
- C. When the cervix is completely dilated.
- D. When the cervix is completely effaced.
Correct answer: C
Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal. Choices A, B, and D are incorrect because pushing before complete dilation can be harmful and may not effectively help in the descent of the baby. The presence of an anterior or posterior lip of the cervix, the urge to have a bowel movement, or complete effacement of the cervix are not indicators for the initiation of pushing during labor.
2. What is the most common cause of coronary artery disease?
- A. Atherosclerosis.
- B. Hyperlipidemia.
- C. Diabetes.
- D. Smoking.
Correct answer: A
Rationale: The correct answer is Atherosclerosis. It is the primary cause of coronary artery disease, as it involves the buildup of plaque in the arteries, restricting blood flow to the heart. Hyperlipidemia (choice B) contributes to atherosclerosis by increasing cholesterol levels in the blood but is not the direct cause of coronary artery disease. Diabetes (choice C) can accelerate atherosclerosis due to high blood sugar levels, but it is not the most common cause. Smoking (choice D) is a significant risk factor for developing coronary artery disease but is not the primary cause.
3. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which clinical finding requires immediate intervention?
- A. Fever of 100.4°F
- B. Heart rate of 110 beats per minute
- C. Blood pressure of 140/90 mmHg
- D. Respiratory rate of 24 breaths per minute
Correct answer: A
Rationale: A fever of 100.4°F is a clinical finding that requires immediate intervention in a client with ESRD scheduled for hemodialysis. Fever may indicate an underlying infection, which can be severe in individuals with compromised renal function. Prompt assessment and treatment are essential to prevent worsening of the infection and potential complications. Heart rate, blood pressure, and respiratory rate are also important parameters to monitor in clients with ESRD, but in this scenario, the fever takes precedence due to its potential to indicate a critical condition that requires urgent attention.
4. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?
- A. Refer to the risk manager
- B. Notify the healthcare provider
- C. Discontinue the ventilator
- D. Review the medical record
Correct answer: B
Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.
5. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct answer: B
Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.