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. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Processed cheese
- C. Whole grain bread
- D. Fresh vegetables
Correct answer: B
Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.
3. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?
- A. Weakness and fatigue
- B. Intestinal cramping
- C. Weight loss
- D. Jaundiced sclera
Correct answer: D
Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.
4. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed on intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak the NG tube in warm water
- B. Insert the tube with the client's head tilted back
- C. Apply suction while inserting the tube
- D. Elevate the head of the bed 60 to 90 degrees
Correct answer: D
Rationale: Elevating the head of the bed 60 to 90 degrees is the correct intervention to facilitate proper placement of the NG tube. This position helps to use gravity to guide the tube smoothly into the gastrointestinal tract. Soaking the NG tube in warm water (Choice A) is not necessary for proper placement. Inserting the tube with the client's head tilted back (Choice B) can cause discomfort and may lead to improper placement. Applying suction while inserting the tube (Choice C) is not recommended as it can cause trauma to the nasal passages and esophagus.
5. A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?
- A. Complete blood count (CBC)
- B. Activated partial thromboplastin time (aPTT)
- C. Prothrombin time (PT)
- D. International normalized ratio (INR)
Correct answer: B
Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.
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