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. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
- A. purulent exudate
- B. warmth
- C. skin blanching
- D. bleeding
Correct answer: C
Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice A) is associated with infection, warmth (choice B) can indicate phlebitis, and bleeding (choice D) may occur if the IV catheter punctures a blood vessel.
3. What is important to include in discharge instructions for a child who has had a tonsillectomy?
- A. Encourage the child to gargle with salt water
- B. Encourage fluid intake
- C. Provide the child with hard candy
- D. Apply heat to the neck
Correct answer: B
Rationale: Encouraging fluid intake is essential post-tonsillectomy to keep the throat moist, aid in healing, and prevent dehydration. Gargling with salt water may irritate the surgical site and is typically avoided to prevent discomfort and irritation. Providing hard candy can be harmful as it may cause trauma to the surgical area and should be avoided to prevent injury. Applying heat to the neck is not recommended as it can increase swelling and discomfort in the surgical region. Therefore, the correct instruction is to encourage fluid intake.
4. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?
- A. Tissue sloughing upon extravasation
- B. Elevated blood pressure and heart rate
- C. Tinnitus and vertigo
- D. Erythema of the face, neck, and chest
Correct answer: C
Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.
5. The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?
- A. These are normal signs of aging.
- B. These are early signs of dementia.
- C. These are purely psychological in origin.
- D. These are common manifestations with UTIs.
Correct answer: D
Rationale: The nurse should interpret confusion and agitation in an older adult patient with a UTI as common manifestations of the infection. In older patients, confusion is a primary symptom of a compromised state due to an acute urinary tract infection or fever. Choice A is incorrect as confusion and agitation are not normal signs of aging. Choice B is incorrect because these symptoms are more likely related to the UTI rather than early signs of dementia. Choice C is incorrect as confusion and agitation in this context are not purely psychological but are likely physiological responses to the UTI.