HESI LPN
Community Health HESI Test Bank 2023
1. The nurse uses the DRG (Diagnosis Related Group) manual to
- A. Classify nursing diagnoses from the client's health history
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct answer: C
Rationale: The DRG manual is used to determine the reimbursement rate for medical diagnoses and treatments under the prospective payment system used by healthcare facilities. Choice A is incorrect because the DRG manual is not used to classify nursing diagnoses, but rather to group medical diagnoses for billing purposes. Choice B is incorrect as the DRG manual is not used to identify findings related to medical diagnoses, but rather to standardize payments for medical services. Choice D is incorrect as the DRG manual is not used to implement nursing care based on case management protocol, but rather to set reimbursement rates.
2. The nurse is admitting a client from the post-anesthesia unit to the postoperative surgical care unit. Which intervention should the nurse implement first?
- A. Advance to clear liquids as tolerated
- B. Straight catheterization if unable to void
- C. Administer Cefazolin 1 gram IVPQ q6 hours
- D. Obtain a complete blood cell count (CBC) in the morning
Correct answer: B
Rationale: The correct answer is to perform straight catheterization if the client is unable to void. This action is essential to prevent urinary retention and its potential complications following anesthesia. Option A, advancing to clear liquids, is not the priority upon admission as the focus should be on urinary function first. Option C involves administering an antibiotic, which is important but not the immediate priority. Option D, obtaining a CBC, can be done later and is not as crucial as ensuring proper urinary function postoperatively.
3. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?
- A. Encourage the client to relax and take deep breaths during the dressing change.
- B. Educate the client about the importance of pain management postoperatively.
- C. Assist the client to a comfortable position for the dressing change.
- D. Administer pain medication 45 minutes before changing the client's dressing.
Correct answer: D
Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.
4. A parent brings an 18-month-old toddler to the clinic. The parent states, 'My child is so difficult to please, has temper tantrums, and annoys me by throwing food from the table.' What is the nurse’s best response?
- A. “Toddlers need discipline to prevent the development of antisocial behaviors.”
- B. “Toddlers are learning to assert independence, and this behavior is expected at this age.”
- C. “It is best to leave the toddler alone in the crib after calmly explaining why the behavior is unacceptable.”
- D. “This is the way a toddler expresses needs, and this behavior is acceptable during the initiative stage of development.”
Correct answer: B
Rationale: The correct answer is B: 'Toddlers are learning to assert independence, and this behavior is expected at this age.' At 18 months old, toddlers are in the stage of developing autonomy and testing boundaries. It is normal for them to exhibit behaviors such as temper tantrums and defiance as they explore their independence. Choice A is incorrect as discipline at this age is more about setting limits and providing guidance rather than preventing antisocial behaviors. Choice C is inappropriate as leaving a toddler alone in a crib after explaining unacceptable behavior is not a recommended approach for managing toddler behavior. Choice D is incorrect as the described behavior is typical of toddlers asserting independence, not related to the initiative stage of development. The best response involves acknowledging the child's developmental stage and understanding that these behaviors are part of their normal growth and development.
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.