HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. What could suddenly occur in a child with acute epiglottitis?
- A. Increased carbon dioxide levels
- B. Airway obstruction
- C. Inability to swallow
- D. Bronchial collapse
Correct answer: B
Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.
2. A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?
- A. Perform a physical assessment
- B. Review the client's medication list
- C. Instruct the client to elevate the legs
- D. Obtain a detailed dietary history
Correct answer: A
Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.
3. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis?
- A. Low serum albumin
- B. High serum cholesterol
- C. Abnormally low white blood cell count
- D. Elevated creatinine phosphokinase (CPK)
Correct answer: D
Rationale: The correct answer is D: Elevated creatinine phosphokinase (CPK). Elevated CPK levels indicate muscle damage, including damage to the cardiac muscle, which aligns with the diagnosis of myocardial infarction. Choice A, low serum albumin, is not directly related to myocardial infarction. Choice B, high serum cholesterol, is more associated with conditions like atherosclerosis rather than acute myocardial infarction. Choice C, abnormally low white blood cell count, is typically not a lab value associated with myocardial infarction; instead, it could suggest other conditions like infections or bone marrow issues.
4. When admitting a client with an abdominal wound, which precaution should be taken?
- A. Contact precautions
- B. Droplet precautions
- C. Airborne precautions
- D. Standard precautions
Correct answer: A
Rationale: When admitting a client with an abdominal wound, contact precautions should be implemented. Contact precautions are used to prevent the spread of infections that are spread by direct or indirect contact. In the case of abdominal wounds, bacteria and pathogens can easily be transmitted through contact with the wound or wound drainage. Droplet precautions are used for infections transmitted through respiratory droplets, such as influenza. Airborne precautions are used for infections spread through the air, like tuberculosis. Standard precautions are used for all clients to prevent the spread of infections and should be followed in addition to specific precautions based on the type of infection.
5. When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?
- A. Repeat each joint motion five times during each session.
- B. Perform the exercises quickly to save time.
- C. Focus only on the most affected joints.
- D. Assess the client's range of motion before starting.
Correct answer: A
Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.