HESI LPN
Medical Surgical HESI
1. What are early signs of varicella disease?
- A. High fever over 101°F (38.3°C)
- B. General malaise
- C. Increased appetite
- D. Crusty sores
Correct answer: B
Rationale: The correct early sign of varicella disease is general malaise. During the prodromal period, patients may experience low-grade fever, malaise, and anorexia. Increased appetite and crusty sores are not typically early signs of varicella. The appearance of lesions occurs later in the course of the disease.
2. The nurse is assessing a client with hyperkalemia. Which finding is consistent with this electrolyte imbalance?
- A. Muscle weakness
- B. Decreased deep tendon reflexes
- C. Constipation
- D. Hypotension
Correct answer: A
Rationale: Muscle weakness is a common finding in clients with hyperkalemia. Hyperkalemia can lead to muscle weakness due to the effect of high potassium levels on muscle function. Decreased deep tendon reflexes (Choice B) are not typically associated with hyperkalemia; instead, hyperreflexia or increased reflexes may be observed. Constipation (Choice C) is not a common symptom of hyperkalemia. Hypotension (Choice D) is also not a typical finding in hyperkalemia; instead, hypertension or normal blood pressure may be present.
3. A client asks a nurse about their Snellen eye test results. The client's visual acuity is 20/30. Which of the following responses should the nurse make?
- A. “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.”
- B. “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.”
- C. “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.”
- D. “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.”
Correct answer: A
Rationale: The correct answer is A: 'Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.' In the Snellen eye test, a visual acuity of 20/30 means that the client sees at 20 feet what a person with normal vision sees at 30 feet. This indicates that the client's vision is slightly worse than average. Choice B is incorrect as it incorrectly describes the visual acuity of each eye individually, rather than the combined visual acuity. Choice C is incorrect as it misinterprets the meaning of the Snellen eye test results by reversing the values. Choice D is incorrect as it inaccurately describes the visual acuity of the client's eyes, attributing different visual acuities to each eye instead of a combined measurement as indicated by 20/30.
4. Which individual has the highest risk of developing community-acquired pneumonia?
- A. A 40-year-old first-grade teacher who works with underprivileged children.
- B. A 75-year-old retired secretary with exercise-induced wheezing.
- C. A 60-year-old homeless person who is an alcoholic and smokes.
- D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.
Correct answer: C
Rationale: The correct answer is the 60-year-old homeless person who is an alcoholic and smokes. This individual has the highest risk of developing community-acquired pneumonia due to factors such as homelessness, alcoholism, and smoking, which weaken the immune system and make them more susceptible to respiratory infections. Choice A is incorrect as working with underprivileged children, while potentially exposing the individual to various illnesses, does not directly increase the risk of pneumonia. Choice B is less likely as exercise-induced wheezing may suggest asthma but does not directly correlate with pneumonia risk. Choice D, an aerobics instructor who eats only vegetables and skips meals, does not have the same level of risk factors for pneumonia as the homeless person in choice C.
5. What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele?
- A. Positioning the infant supine with a pillow under the buttocks
- B. Covering the sac with saline-soaked nonadhesive gauze
- C. Wrapping the infant snugly in a blanket
- D. Applying a diaper to prevent fecal soiling of the sac
Correct answer: B
Rationale: The correct answer is B: Covering the sac with saline-soaked nonadhesive gauze. This intervention is essential in caring for an infant with myelomeningocele as it helps prevent infection and maintains a moist environment around the sac before surgical repair. Positioning the infant supine with a pillow under the buttocks (Choice A) may be suitable for comfort but is not directly related to managing the myelomeningocele. Wrapping the infant snugly in a blanket (Choice C) and applying a diaper (Choice D) are not recommended as they can increase the risk of infection and damage to the sac.