HESI LPN
Medical Surgical HESI
1. The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver.
- B. Oranges.
- C. Leafy green vegetables.
- D. Kidney beans.
Correct answer: B
Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.
2. An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF). Which actions should the nurse take in providing care? (Select all that apply)
- A. Monitor electrolyte levels.
- B. Maintain pulse oximetry.
- C. Provide assistance with mobility.
- D. All of the Above
Correct answer: D
Rationale: In a patient with COPD and HF, monitoring electrolyte levels is essential due to potential imbalances caused by medications or fluid shifts. Maintaining pulse oximetry is crucial to assess oxygenation status in COPD and HF. Providing assistance with mobility helps prevent deconditioning and complications. Therefore, all the actions mentioned are necessary for comprehensive care in this scenario, making option D the correct answer. Choices A, B, and C are all important aspects of managing COPD and HF, ensuring holistic and effective care.
3. After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first?
- A. Reorient the client to the room
- B. Place an eye patch on one eye
- C. Evaluate the client's ability to swallow
- D. Perform range of motion exercises
Correct answer: C
Rationale: Evaluating the client's ability to swallow is the priority intervention in this scenario. Pontine myelinolysis can affect neurological functions, including swallowing ability, putting the client at risk for aspiration. Assessing the client's ability to swallow will help prevent complications such as aspiration pneumonia. Reorienting the client to the room, placing an eye patch, or performing range of motion exercises are not as critical as ensuring the client can safely swallow.
4. The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)
- A. Abdominal obesity
- B. Blood pressure of 150/96 mmHg
- C. Increased triglyceride levels
- D. All of the above
Correct answer: D
Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.
5. Which statement correctly explains the etiology of Down syndrome?
- A. There is an extra chromosome on the 21st pair.
- B. There is a missing chromosome on the 21st pair.
- C. There are two pairs of the 21st chromosome.
- D. The 21st chromosome pair is missing.
Correct answer: A
Rationale: The correct answer is A: 'There is an extra chromosome on the 21st pair.' Down syndrome is caused by the presence of an extra copy of chromosome 21, known as trisomy 21. This additional genetic material leads to the characteristics associated with Down syndrome. Choices B, C, and D are incorrect because Down syndrome is not due to a missing chromosome or having two pairs of the 21st chromosome; it results from the presence of an extra chromosome on the 21st pair.
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