HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. Which is a priority nursing intervention for the cognitively impaired child?
- A. The family will provide good nutrition.
- B. The family will provide loving interactions.
- C. Stimulation will improve.
- D. There will be contact with peers.
Correct answer: B
Rationale: The correct answer is B because nursing interventions for cognitively impaired children prioritize promoting loving interactions with family. This support helps in creating a nurturing environment that contributes to the child's well-being and development. Choice A is not the priority as good nutrition, though important, may not address the immediate emotional and social needs of the child. Choice C is vague and does not specify how stimulation will be provided. Choice D, contact with peers, is also valuable but not as crucial as the primary relationships and interactions within the family unit for a cognitively impaired child.
2. A client with Cushing's Syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter-sized blood spot on the dressing
- D. Pitting ankle edema
Correct answer: A
Rationale: The correct answer is A: Irregular apical pulse. In a client recovering from a laparoscopic procedure with Cushing's Syndrome, an irregular apical pulse can be indicative of a life-threatening arrhythmia and requires immediate intervention. Choices B, C, and D are not as urgent as an irregular apical pulse. Purple marks on the skin of the abdomen may be related to Cushing's Syndrome, a quarter-sized blood spot on the dressing can be managed with appropriate wound care, and pitting ankle edema may be expected postoperatively but does not require immediate intervention.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?
- A. Increased respiratory rate
- B. Decreased level of consciousness
- C. Improved oxygen saturation
- D. Complaints of dry mouth
Correct answer: B
Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.
4. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
- A. Alcohol
- B. Mineral oil
- C. Calamine
- D. A&D ointment
Correct answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
5. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
- A. Increase the daily intake of oral fluids to liquefy secretions
- B. Avoid crowded enclosed areas to reduce pathogen exposure
- C. Call the clinic if undesirable side effects of medications occur
- D. Teach anxiety reduction methods for feelings of suffocation
Correct answer: A
Rationale: Increasing fluid intake is crucial as it helps to thin mucus secretions, making them easier to expectorate. This can alleviate the client's symptoms of shortness of breath and productive cough. Option B is not the most important action in this scenario, as it does not directly address the client's respiratory distress. Option C, while important, focuses on medication side effects rather than addressing the immediate breathing difficulties. Option D, teaching anxiety reduction methods, is not the priority when the client's main concern is respiratory distress.
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