HESI LPN
Medical Surgical HESI 2023
1. When speaking to young parents, the nurse states that lead poisoning is one of the most common preventable health problems affecting children. What condition occurs when the level of lead ingested exceeds the amount that can be absorbed by the bone?
- A. Malnutrition
- B. Anemia
- C. Bone pain
- D. Diarrhea
Correct answer: B
Rationale: The correct answer is B: Anemia. When the amount of lead ingested exceeds the amount that can be absorbed by the bone, it leads to anemia. Malnutrition (Choice A) is a state of inadequate nutrition, not directly related to lead poisoning. Bone pain (Choice C) is a symptom of lead poisoning due to its effects on bones but not directly related to lead ingestion exceeding absorption. Diarrhea (Choice D) is not a direct consequence of lead ingestion exceeding absorption by bones.
2. What could suddenly occur in a child with acute epiglottitis?
- A. Increased carbon dioxide levels
- B. Airway obstruction
- C. Inability to swallow
- D. Bronchial collapse
Correct answer: B
Rationale: In acute epiglottitis, the infected epiglottis becomes inflamed and can lead to sudden airway obstruction, which is a life-threatening emergency. This can cause difficulty breathing and necessitates immediate intervention to secure the airway. Increased carbon dioxide levels may occur due to inadequate ventilation resulting from airway obstruction, but the primary concern is the obstruction itself, not the carbon dioxide levels. Inability to swallow may be present due to pain and swelling in the throat but is not the immediate life-threatening complication associated with acute epiglottitis. Bronchial collapse is not a typical consequence of acute epiglottitis.
3. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?
- A. Breathe deeply, followed by swallowing.
- B. Breathe deeply, followed by spitting into a cup.
- C. Breathe deeply, followed by coughing up the sputum.
- D. Breathe deeply, followed by clearing the throat.
Correct answer: C
Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.
4. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?
- A. Inflammation of the vessels
- B. Obstructed blood flow
- C. Overhydration
- D. Stress-related headaches
Correct answer: B
Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.
5. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?
- A. Administer a sedative.
- B. Determine the client’s blood pressure.
- C. Apply soft restraints.
- D. Call for assistance.
Correct answer: B
Rationale: The correct intervention the nurse should implement first is to determine the client’s blood pressure. Assessing the blood pressure is crucial in this situation to rule out physiological causes like hypotension leading to the client's disorientation. Administering a sedative (Choice A) without understanding the underlying cause may worsen the situation. Applying soft restraints (Choice C) should not be the initial action and can be considered later if necessary. Calling for assistance (Choice D) may be needed eventually, but assessing the client's blood pressure takes precedence to address the immediate concern.
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