HESI LPN
Medical Surgical HESI
1. Which dietary modification is most appropriate for a client with nephrotic syndrome?
- A. High protein, low sodium
- B. Low protein, high sodium
- C. High protein, high potassium
- D. Low protein, low sodium
Correct answer: D
Rationale: The most appropriate dietary modification for a client with nephrotic syndrome is a low protein, low sodium diet. This diet helps reduce the workload on the kidneys and manage edema, which are common issues in nephrotic syndrome. Choice A, high protein, low sodium, is not recommended because excessive protein intake can further strain the kidneys. Choice B, low protein, high sodium, is inappropriate as high sodium can worsen fluid retention and hypertension. Choice C, high protein, high potassium, is not ideal as high potassium levels can be problematic for individuals with kidney issues.
2. To assess the quality of an adult client’s pain, what approach should the nurse use?
- A. Ask the client to rate the pain on a scale of 1 to 10.
- B. Ask the client to describe the pain.
- C. Observe the client’s nonverbal cues.
- D. Determine the client’s pain tolerance.
Correct answer: B
Rationale: The correct approach for assessing the quality of an adult client's pain is to ask the client to describe the pain. By doing so, the nurse gains valuable information about the quality, location, and nature of the pain directly from the client. This approach allows for a more comprehensive understanding of the pain experience. Choice A, asking the client to rate the pain on a scale of 1 to 10, focuses more on intensity rather than quality. Choice C, observing the client's nonverbal cues, can provide additional information but may not fully capture the client's subjective experience of pain. Choice D, determining the client's pain tolerance, is not directly related to assessing the quality of pain but rather to how much pain a client can endure.
3. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.
- A. Increase the room temperature.
- B. Assess the oxygen saturation.
- C. Continue to monitor vital signs.
- D. Notify the rapid response team.
Correct answer: D
Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.
4. A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Apply a sterile dressing to the wound.
- B. Administer an analgesic.
- C. Encourage the client to drink fluids.
- D. Ensure the client's nutritional needs are met.
Correct answer: B
Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.
5. Following a bout of diarrhea, which foods should be offered to the school-age child?
- A. Apricots and peaches
- B. Chocolate milk
- C. Applesauce and milk
- D. Bananas and rice
Correct answer: D
Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.
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