HESI LPN
HESI Test Bank Medical Surgical Nursing
1. What is the hallmark sign of intussusception?
- A. Mucus-like stools
- B. Currant jelly-like stools
- C. Tarry, black stools
- D. Green, soft stools
Correct answer: B
Rationale: The hallmark sign of intussusception is currant jelly-like stools, which result from the mixture of blood and mucus in the stool due to the sloughing of intestinal mucosa. Mucus-like stools (Choice A) are not typically associated with intussusception. Tarry, black stools (Choice C) are characteristic of gastrointestinal bleeding higher up in the gastrointestinal tract, such as from a peptic ulcer. Green, soft stools (Choice D) are more indicative of rapid transit through the intestines, possibly due to dietary factors or infections such as gastroenteritis.
2. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
- A. Alcohol
- B. Mineral oil
- C. Calamine
- D. A&D ointment
Correct answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
3. A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Increase oxygen flow rate during physical activity
- B. Smoke at least 10 feet away from the oxygen source
- C. Use petroleum jelly to prevent nasal dryness
- D. Ensure the oxygen tank is stored in a secure upright position
Correct answer: D
Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.
4. An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?
- A. The medication should be used for 10 weeks only.
- B. The medication requires that sexually active females use contraception.
- C. The medication lowers hemoglobin levels very quickly.
- D. The medication has few side effects.
Correct answer: B
Rationale: The correct guidance the nurse should provide is that sexually active females must use contraception while taking Accutane and for 1 month after the 20 weeks it is prescribed. Choice A is incorrect because Accutane is typically taken for a longer duration than 10 weeks. Choice C is incorrect because Accutane does not lower hemoglobin levels quickly. Choice D is incorrect as Accutane is known for having many side effects, including the risk of birth defects.
5. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in LOC
Correct answer: D
Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.
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