HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site.
- A. Ensure the client is NPO and document the last meal.
- B. Administer pain medication as prescribed.
- C. Apply a sterile dressing to the wound site.
- D. Notify the healthcare provider of the client’s medication history.
Correct answer: D
Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.
2. Which goal is most appropriate for a patient who has had a total hip replacement?
- A. The patient will ambulate briskly on the treadmill by the time of discharge.
- B. The patient will walk 100 feet using a walker by the time of discharge.
- C. The nurse will assist the patient to ambulate in the hall 2 times a day.
- D. The patient will ambulate by the time of discharge.
Correct answer: B
Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.
3. The nurse is working in a community health clinic that serves a diverse population. Which of the following actions best demonstrates cultural competence?
- A. Learning about the cultural practices of the clinic's client population
- B. Providing translation services for non-English speaking clients
- C. Treating all clients the same regardless of their background
- D. Encouraging clients to adopt mainstream health practices
Correct answer: A
Rationale: Learning about the cultural practices of the clinic's client population is the best way to demonstrate cultural competence. This action shows respect for the diverse backgrounds of the clients and helps in providing care that is sensitive to their cultural beliefs and practices. Providing translation services (Choice B) is important for effective communication but may not address the deeper aspects of cultural competence. Treating all clients the same (Choice C) may overlook the unique needs that arise from cultural differences. Encouraging clients to adopt mainstream health practices (Choice D) may not be appropriate or respectful of their cultural traditions and preferences.
4. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?
- A. Notify the provider about the client's decision
- B. Proceed with the transport
- C. Prepare the surgical site
- D. Document the client’s statement
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.
5. What is the most effective therapy for maintaining remission of acute lymphoblastic leukemia?
- A. Surgery to remove enlarged lymph nodes
- B. Long-term chemotherapy
- C. Nutritional supplements to enhance blood cell production
- D. Blood transfusions to replace ineffective red cells
Correct answer: B
Rationale: The correct answer is B: Long-term chemotherapy. Long-term chemotherapy, specifically with methotrexate, is the most effective therapy for maintaining remission in acute lymphoblastic leukemia. Surgery to remove enlarged lymph nodes (Choice A) is not the primary treatment for leukemia. Nutritional supplements (Choice C) may support overall health but are not the mainstay therapy for maintaining leukemia remission. Blood transfusions (Choice D) are used to address anemia in some cases but are not the primary treatment for maintaining remission in acute lymphoblastic leukemia.