HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do your family members share combs and brushes?
- D. Do you have any dry patches on your feet and hands?
Correct answer: A
Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.
2. A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?
- A. You may experience dizziness, so avoid driving.
- B. It may take several weeks to feel the full effect of the medication.
- C. Avoid foods high in tyramine while taking this medication.
- D. Take this medication only when you feel depressed.
Correct answer: B
Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.
3. When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)
- A. 42
- B. 38
- C. 48
- D. 50
Correct answer: A
Rationale: By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.
4. Which of the following processes happen during mitosis?
- A. Strands of deoxyribonucleic acid (DNA) break apart.
- B. Adenine combines with its appropriate partner, cytosine.
- C. Sperm and ova cells are created.
- D. Twenty-three chromosomes are created.
Correct answer: A
Rationale: The correct process that happens during mitosis is the breaking apart, replication, and division of DNA strands into two new cells, each with the same number of chromosomes as the original cell. Choice B is incorrect because it describes base pairing in DNA, not a process specific to mitosis. Choice C is incorrect as the creation of sperm and ova cells is related to meiosis, not mitosis. Choice D is incorrect because chromosomes are not created during mitosis; they are replicated and divided equally between the daughter cells.
5. A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.