HESI LPN
Medical Surgical HESI 2023
1. When interacting with the parents of a SIDS infant, the nurse should attempt to assist the parents with:
- A. Encouraging the parents to have another baby.
- B. Encouraging the parents to remain stoic.
- C. Allaying feelings of guilt and blame.
- D. Learning how the event could have been prevented.
Correct answer: C
Rationale: The correct answer is C: Allaying feelings of guilt and blame. When parents experience the loss of a SIDS infant, they often struggle with intense feelings of guilt and self-blame. The nurse's role is to provide emotional support and help alleviate these feelings. Choices A and B are incorrect as encouraging the parents to have another baby or to remain stoic is not appropriate or helpful in this situation. Choice D is also incorrect because focusing on how the event could have been prevented may exacerbate feelings of guilt and is not the immediate priority in supporting grieving parents.
2. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?
- A. Neutralizes stomach acid
- B. Decreases gastric acid secretion
- C. Covers the ulcer site and protects it from acid
- D. Improves gastric motility
Correct answer: C
Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.
3. What is a priority action for the nurse when caring for a client with suspected meningitis?
- A. Isolate the client in a private room
- B. Administer intravenous antibiotics
- C. Obtain a throat culture
- D. Perform a chest x-ray
Correct answer: B
Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.
4. An older female client has normal saline infusing at 45 ml/hour. She complains of pain at the insertion of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
- A. Determine what IV medications have recently been administered.
- B. Slow the infusion rate.
- C. Apply a warm compress to the IV site.
- D. Discontinue the IV line and start a new one.
Correct answer: A
Rationale: The correct action for the nurse to take in this scenario is to determine what IV medications have recently been administered. This is important to identify if the pain at the IV site is related to a medication infusion. Slowing the infusion rate (choice B) may not address the underlying cause of the pain. Applying a warm compress (choice C) is not necessary since there is no redness or edema around the IV site. Discontinuing the IV line and starting a new one (choice D) is a drastic step and should not be the first action taken without investigating the cause of the pain.
5. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
- A. Document the client's report of pain in the electronic medical record.
- B. Determine which prescription will have the quickest onset of action.
- C. Compare the client's pain scale rating with the prescribed dosing.
- D. Ask the client to choose which medication is needed for the pain.
Correct answer: C
Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.
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