HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
2. A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?
- A. Report any signs of a sore throat or fever immediately
- B. Take the medication with antacids to reduce stomach upset
- C. Discontinue the medication if you feel drowsy
- D. Increase the dosage if you experience an aura
Correct answer: A
Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention. Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption. Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time. Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.
3. The client has been diagnosed with deep vein thrombosis (DVT). Which symptom would be most concerning?
- A. Pain in the affected leg
- B. Redness and warmth in the affected leg
- C. Shortness of breath
- D. Swelling in the affected leg
Correct answer: C
Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.
4. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?
- A. I will straighten my ear canal by pulling my ear down and back.
- B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snugly into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct answer: B
Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.
5. What is the most common cause of shock (hypoperfusion) in infants and children?
- A. infection
- B. cardiac failure
- C. accidental poisoning
- D. severe allergic reaction
Correct answer: A
Rationale: Infection is the leading cause of shock in infants and children due to their heightened vulnerability to sepsis. Infants and children possess developing immune systems, rendering them more susceptible to infections that can progress to septic shock. While cardiac failure is a severe condition, it is not as commonly the primary cause of shock in this age group. Accidental poisoning, though a potential shock inducer, is less prevalent in infants and children compared to infections. Severe allergic reactions, though significant, are not as frequent as infections in precipitating shock in infants and children.