HESI LPN
Medical Surgical HESI
1. When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?
- A. Increased temperature
- B. Constipation
- C. Right quadrant pain
- D. Exercise-associated pain
Correct answer: B
Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.
2. 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.
3. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?
- A. Leaving the lesion uncovered and placing the infant supine
- B. Covering the lesion with a sterile, saline-soaked gauze
- C. Applying lotion to the lesion to keep it moist
- D. Covering the lesion with a dry, sterile gauze
Correct answer: B
Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.
4. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
- A. Two liters.
- B. Three liters.
- C. Four liters.
- D. Five liters.
Correct answer: B
Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.
5. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- A. Nuchal rigidity
- B. Carotid bruit
- C. Jugular vein distention
- D. Palpable cervical lymph node
Correct answer: B
Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.
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