HESI LPN
HESI Test Bank Medical Surgical Nursing
1. The family of a newly admitted child with cystic fibrosis is educated by the nurse that the treatment will be centered on what therapy?
- A. Chest physiotherapy
- B. Mucus-drying agents
- C. Prevention of diarrhea
- D. Insulin therapy
Correct answer: A
Rationale: The correct answer is A: Chest physiotherapy. In cystic fibrosis, chest physiotherapy and aerosol medications are fundamental components of treatment to help clear mucus from the lungs, reduce the risk of infections, and improve breathing. Mucus-drying agents (Choice B) are not typically used in the treatment of cystic fibrosis. Prevention of diarrhea (Choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (Choice D) is not relevant to cystic fibrosis, as it is a treatment for diabetes.
2. The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
3. What are early signs of varicella disease?
- A. High fever over 101°F (38.3°C)
- B. General malaise
- C. Increased appetite
- D. Crusty sores
Correct answer: B
Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.
4. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.
5. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to hemothorax?
- A. Keep the arm and shoulder of the affected side immobile at all times.
- B. Encourage the client to breathe deeply and cough at frequent intervals.
- C. Maintain the pleura vac slightly above the chest level.
- D. Ensure there is no fluctuation in the water seal.
Correct answer: B
Rationale: Encouraging deep breathing and coughing is vital for a client with a chest tube due to hemothorax as it helps prevent atelectasis and promotes lung expansion. Keeping the arm and shoulder immobile (Choice A) is not necessary for chest tube management. Maintaining the pleura vac slightly above the chest level (Choice C) is incorrect as the pleura vac should be kept below the chest level to facilitate drainage. Ensuring no fluctuation in the water seal (Choice D) is important, but it is not the priority intervention when compared to promoting lung expansion through deep breathing and coughing.
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