HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.
2. A nurse is receiving a verbal prescription from the provider for a client who is experiencing increased pain. The nurse should transcribe which of the following prescriptions in the client's medical record?
- A. Morphine sulfate 10 mg IV q 4 IV prn for pain
- B. MS 10 mg IV every 4 8 prn for pain
- C. MSO4 10 mg IVP q 4 8 prn for pain
- D. Morphine sulfate 10.0 mg every 4 hours IV prn for pain
Correct answer: A
Rationale: The correct transcription is 'Morphine sulfate 10 mg IV q 4 IV prn for pain.' In choice A, 'Morphine sulfate 10 mg IV q 4 IV prn for pain' correctly indicates the medication, route (IV), frequency (every 4 hours), and administration as needed for pain control. Choice B is incorrect as 'MS' is not a standard abbreviation for Morphine Sulfate, and the frequency 'every 4 8' is not a valid time interval. Choice C is incorrect as 'MSO4' is not the standard abbreviation for Morphine Sulfate, and 'IVP' is not the standard route abbreviation for intravenous. Choice D is incorrect as it lacks clarity with '10.0 mg' instead of '10 mg,' and the frequency is given as 'every 4 hours' without specifying the route of administration.
3. A client with chronic kidney disease is prescribed sevelamer. The nurse should monitor for which potential side effect?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct answer: B
Rationale: When a client with chronic kidney disease is prescribed sevelamer, the nurse should monitor for hypocalcemia. Sevelamer works by binding dietary phosphorus in the gastrointestinal tract, which can lead to decreased calcium absorption and potentially cause hypocalcemia.
4. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to
- A. Assess for abdominal distention
- B. Maintain the infant in an upright position
- C. Begin feeding formula when the infant is alert
- D. Pump the shunt to assess for proper function
Correct answer: A
Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.
5. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?
- A. You are in the hospital, and I am the nurse caring for you
- B. It must be difficult for you to control your anxious feelings
- C. Go to occupational therapy and start a project
- D. You are not in a war area now; this is the United States
Correct answer: C
Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.