HESI LPN
Medical Surgical HESI
1. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?
- A. Broccoli
- B. Chicken breast
- C. White bread
- D. Apple
Correct answer: A
Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.
2. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
- A. Remove the cap and apply direct gentle pressure with the syringe
- B. Contact the healthcare provider regarding the need for a chest x-ray
- C. Cover the cap with tape and label the port as being obstructed
- D. Remove the catheter while applying gentle pressure at the insertion site
Correct answer: B
Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.
3. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?
- A. Mild soap and water
- B. A cotton ball
- C. Mineral oil
- D. Alcohol swabs
Correct answer: C
Rationale: To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (Choice A) may not be effective in completely removing zinc oxide. A cotton ball (Choice B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (Choice D) can be harsh on the skin and are not recommended for this purpose.
4. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
- A. Evaluate electrolytes
- B. Restrict fluid intake
- C. Administer diuretics
- D. Monitor vital signs
Correct answer: A
Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.
5. The nurse is triaging clients who have been injured during a tornado. Which client requires immediate action?
- A. A young male with a minor laceration on his forearm.
- B. An elderly woman with a dislocated shoulder who is calm.
- C. A middle-aged female with a broken humerus who is unable to follow commands and is crying.
- D. A teenager with abrasions and a bruised knee.
Correct answer: C
Rationale: The middle-aged female with a broken humerus who is unable to follow commands and is crying requires immediate action. These symptoms indicate a possible head injury or severe emotional distress that need urgent attention. Choice A is not as urgent since a minor laceration can be addressed after more critical cases. Choice B, although having a dislocated shoulder, is stable, as the client is calm. Choice D presents with minor injuries that can wait while more critical cases are addressed.