HESI LPN
Medical Surgical HESI 2023
1. In a disaster area, a nurse assesses an adult male with partial-thickness burns on his lower legs, approximately 10% of his lower body. Which color of triage tag should the nurse place on this client?
- A. Yellow.
- B. Black.
- C. Red.
- D. Green.
Correct answer: A
Rationale: A yellow triage tag should be placed on the client with partial-thickness burns covering 10% of his lower body. Yellow tags indicate delayed treatment, suitable for serious injuries that are not immediately life-threatening. Black tags are used for deceased individuals, red tags for immediate treatment of life-threatening injuries, and green tags for minor injuries.
2. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the brace
- D. Spending a majority of their time with her
Correct answer: C
Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.
3. 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.
4. The nurse is caring for a client with acute pancreatitis. Which laboratory result is most indicative of this condition?
- A. Elevated serum amylase
- B. Decreased serum bilirubin
- C. Increased blood urea nitrogen (BUN)
- D. Decreased alkaline phosphatase
Correct answer: A
Rationale: Elevated serum amylase is the most indicative laboratory result of acute pancreatitis. In this condition, the pancreas becomes inflamed, leading to the leakage of amylase and lipase into the bloodstream. Elevated serum amylase levels are a classic finding in acute pancreatitis. Choices B, C, and D are not typically associated with acute pancreatitis. Decreased serum bilirubin, increased blood urea nitrogen (BUN), and decreased alkaline phosphatase levels are not specific markers for acute pancreatitis.
5. How is gastroesophageal reflux (GER) typically treated in infants?
- A. By placing the infant NPO
- B. By thickening the formula or breast milk with cereal
- C. By placing the infant to sleep on the side
- D. By switching the infant to cow's milk
Correct answer: B
Rationale: Gastroesophageal reflux (GER) in infants is typically treated by thickening the formula or breast milk with cereal. This helps reduce reflux episodes by making the feedings heavier and less likely to come back up. Placing the infant NPO (nothing by mouth) is not the typical treatment for GER as infants need proper nutrition for growth. Placing the infant to sleep on the side is not recommended due to the risk of SIDS; infants should be placed on their back to sleep. Switching the infant to cow's milk is also not a treatment for GER, as cow's milk can be harder to digest and may exacerbate symptoms.
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