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. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which response would be the most correct?
- A. The epinephrine given causes nausea and vomiting.
- B. The child is being hydrated with IV fluids.
- C. The child is not hungry.
- D. The child's rapid respirations pose a risk for aspiration.
Correct answer: D
Rationale: The correct answer is D because rapid respirations predispose to aspiration in a child with acute laryngotracheobronchitis. Choice A is incorrect because epinephrine does not directly relate to the need for NPO status. Choice B is incorrect as hydration with IV fluids is not the primary reason for keeping the child NPO. Choice C is incorrect as the child being hungry is not the main concern when keeping a child NPO in this situation.
3. A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement?
- A. Observe the perineal area for a chancroid-like lesion.
- B. Obtain a specimen of urethral drainage for culture.
- C. Assess for perineal itching, erythema, and excoriation.
- D. Identify all sexual partners in the last four days.
Correct answer: B
Rationale: In this scenario, the most appropriate action for the nurse to take is to obtain a specimen of urethral drainage for culture. This procedure can help diagnose the cause of burning on urination, which could be indicative of a sexually transmitted infection. Option A, observing for a chancroid-like lesion, may not be the most immediate or relevant action in this case. Option C, assessing for perineal itching, erythema, and excoriation, is important but obtaining a culture specimen would provide more specific diagnostic information. Option D, identifying all sexual partners, is relevant for contact tracing but obtaining a culture specimen is the priority to determine the current infection status.
4. The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
- A. Liver.
- B. Oranges.
- C. Leafy green vegetables.
- D. Kidney beans.
Correct answer: B
Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.
5. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?
- A. I need to take the prescribed amount of the drug to get rid of my gout.
- B. I need to take this drug every day to keep from having any flare-ups.
- C. I should take this drug when I have gout attacks to reduce symptoms.
- D. The pain and swelling can be controlled by taking this drug every day.
Correct answer: B
Rationale: Taking allopurinol every day helps to prevent gout flare-ups by reducing uric acid levels.
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