HESI LPN
Medical Surgical HESI 2023
1. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?
- A. Flush the tube with 50 mL of normal saline every 8 hours
- B. Clamp the tube when not in use
- C. Position the client in a supine position
- D. Verify tube placement by checking pH of gastric contents
Correct answer: D
Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.
2. What is an important dietary consideration for a child with renal failure?
- A. Low-protein, low-sodium diet
- B. High-protein, high-sodium diet
- C. Increased calcium intake
- D. High-fiber diet
Correct answer: A
Rationale: A low-protein, low-sodium diet is crucial for a child with renal failure because it helps reduce the workload on the kidneys and minimize complications. High-protein and high-sodium diets can place excessive strain on the kidneys and worsen the condition. Increased calcium intake is not typically a primary consideration for renal failure in children. While a high-fiber diet can be beneficial for overall health, it is not a specific priority for managing renal failure in children.
3. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowler's
- D. Side-lying with head flat
Correct answer: C
Rationale: The correct answer is C, Semi-Fowler's. This position helps to reduce intracranial pressure by promoting venous drainage from the head while maintaining adequate oxygenation. Option A, Trendelenburg position, is incorrect as it involves placing the patient with the head lower than the body, which can increase intracranial pressure. Option B, Prone position, is also incorrect as it involves lying on the stomach, which can further elevate intracranial pressure. Option D, Side-lying with head flat, does not provide the same benefits as the Semi-Fowler's position in terms of promoting venous drainage and maintaining oxygenation in a client with increased intracranial pressure.
4. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?
- A. What should I do? Nothing seems to help.
- B. I have been so tired lately and needed to sleep.
- C. I really think that I don't need to be here.
- D. I don't want to talk. Nothing matters anymore.
Correct answer: D
Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.
5. At 2 years of age, a child is readmitted to the hospital for additional surgery. What is the most important factor in preparing the toddler for this experience?
- A. Meeting the child’s wishes
- B. Previous hospitalization experience
- C. Preventing the child from staying with strangers
- D. Ensuring ongoing parental affection
Correct answer: B
Rationale: The most important factor in preparing a toddler for additional surgery is their previous hospitalization experience. This familiarity with the hospital setting and procedures can help reduce anxiety and fear in the child. Choice A, meeting the child's wishes, may not always align with what is medically necessary or safe for the child. Choice C, preventing the child from staying with strangers, is important for general comfort but may not directly address the child's preparation for surgery. Choice D, ensuring ongoing parental affection, is crucial for emotional support but may not have the same impact as the child's previous hospitalization experience in preparing them for the surgery.