HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?
- A. Leaving the lesion uncovered and placing the infant supine
- B. Covering the lesion with a sterile, saline-soaked gauze
- C. Applying lotion to the lesion to keep it moist
- D. Covering the lesion with a dry, sterile gauze
Correct answer: B
Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.
2. How should hydration status be assessed in a child with vomiting and diarrhea?
- A. Check skin turgor and mucous membranes
- B. Measure blood glucose levels
- C. Assess heart rate and blood pressure
- D. Evaluate bowel sounds
Correct answer: A
Rationale: Checking skin turgor and mucous membranes is the appropriate method to assess hydration status in a child with vomiting and diarrhea. Skin turgor is an indicator of skin elasticity, which decreases when an individual is dehydrated. Mucous membranes, such as the inside of the mouth, can also show signs of dehydration like dryness. Measuring blood glucose levels (choice B) is not relevant to assessing hydration status in this scenario. Assessing heart rate and blood pressure (choice C) is important in evaluating the overall condition of a child but may not directly indicate hydration status. Evaluating bowel sounds (choice D) is more related to assessing gastrointestinal function rather than hydration status.
3. A 4-year-old child is scheduled for a myringotomy. What should the nurse include in the preoperative teaching?
- A. Explain the procedure in simple terms
- B. Encourage fluid intake
- C. Allow the child to play with medical equipment
- D. Use play therapy to prepare the child
Correct answer: A
Rationale: Explaining the procedure in simple terms is essential preoperative teaching for a 4-year-old child scheduled for a myringotomy. This approach helps the child understand what will happen during the procedure, reducing anxiety and fear. Encouraging fluid intake is a good general health practice but not directly related to preoperative teaching for this procedure. Allowing the child to play with medical equipment may not be safe or appropriate as it can lead to misunderstanding or fear. Using play therapy can be beneficial but explaining the procedure in simple terms is more direct and effective for preoperative teaching in this case.
4. A post-operative client is recovering from a total knee replacement and is prescribed patient-controlled analgesia (PCA). What is the primary advantage of PCA for managing post-operative pain?
- A. It allows for consistent pain control without overmedication.
- B. It eliminates the need for oral pain medication.
- C. It reduces the risk of opioid addiction.
- D. It requires less monitoring by nursing staff.
Correct answer: A
Rationale: The primary advantage of PCA for managing post-operative pain is that it allows the client to control the administration of pain medication, leading to consistent pain control without overmedication. Choice B is incorrect as PCA does not eliminate the need for oral pain medication; it supplements it. Choice C is incorrect because while PCA can help reduce opioid consumption, it does not directly reduce the risk of opioid addiction. Choice D is incorrect as PCA actually requires close monitoring by nursing staff to ensure proper use and prevent complications.
5. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?
- A. Encourage the client to eat foods high in protein
- B. Assess the client for daily range of motion exercises
- C. Teach the family how to perform sterile wound care
- D. Ensure the IV fluids are administered as prescribed
Correct answer: A
Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.