HESI LPN
Medical Surgical HESI 2023
1. What most influences the severity of respiratory distress syndrome (RDS)?
- A. Poor cough and gag reflex
- B. The gestational age at birth
- C. Administering high concentrations of oxygen
- D. The sex of the infant
Correct answer: B
Rationale: The correct answer is B. The gestational age at birth most influences the severity of respiratory distress syndrome (RDS). RDS is caused by a deficiency of surfactant and it occurs almost exclusively in preterm, low-birth weight infants. Therefore, the gestational age at birth is a key factor in determining the likelihood and severity of RDS. Choices A, C, and D are incorrect as they do not directly relate to the primary factor influencing the severity of RDS.
2. The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?
- A. Diplopia (double vision)
- B. Difficulty swallowing
- C. Weakness in the legs
- D. Fatigue
Correct answer: B
Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.
3. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?
- A. Potential for injury related to vertigo.
- B. Alteration in comfort due to ear pain.
- C. Impaired skin integrity due to immobility.
- D. Anxiety due to fear of falling.
Correct answer: A
Rationale: The correct answer is A. When caring for a client with Meniere’s disease, the highest priority nursing problem is the potential for injury related to vertigo. Meniere’s disease is characterized by symptoms like vertigo, which can increase the risk of falls and injuries. Ensuring the client's safety and preventing falls take precedence over other concerns. Choices B, C, and D are not the highest priority because they do not directly address the immediate risk of harm associated with vertigo and falls.
4. Which type of lipoprotein is associated with decreasing the risk of atherosclerosis?
- A. High-density lipoprotein (HDL)
- B. Low-density lipoprotein (LDL)
- C. Very low-density lipoprotein (VLDL)
- D. Intermediate-density lipoprotein (IDL)
Correct answer: A
Rationale: The correct answer is High-density lipoprotein (HDL). HDL is known as 'good' cholesterol because it helps remove cholesterol from the arteries, reducing the risk of atherosclerosis. LDL (choice B) is considered 'bad' cholesterol as it can deposit cholesterol in the arteries, increasing the risk of atherosclerosis. VLDL (choice C) and IDL (choice D) are also associated with increased risk of atherosclerosis rather than decreasing it.
5. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct answer: A
Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.
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