HESI LPN
Medical Surgical Assignment Exam HESI
1. What is the best position for a client experiencing a nosebleed?
- A. Sitting up and leaning forward
- B. Lying flat with a pillow under the head
- C. Sitting up and leaning back
- D. Lying on the side with the head elevated
Correct answer: A
Rationale: The best position for a client experiencing a nosebleed is sitting up and leaning forward. This position helps prevent blood from flowing down the throat and reduces the risk of aspiration. Choice B is incorrect as lying flat can lead to blood flowing down the throat. Choice C is also incorrect because leaning back may cause blood to flow backward into the throat. Choice D is incorrect as lying on the side with the head elevated is not the optimal position to manage a nosebleed effectively.
2. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most challenging aspect of care to implement?
- A. Forced fluids
- B. Increased feedings
- C. Bed rest
- D. Frequent position changes
Correct answer: C
Rationale: The correct answer is C: Bed rest. During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very challenging to implement with an active 6-year-old child. Forced fluids (choice A) may be necessary to maintain hydration. Increased feedings (choice B) may not be as difficult to implement as bed rest. Frequent position changes (choice D) may also be important but are not typically the most challenging aspect of care for a child with acute glomerulonephritis.
3. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
- A. Cerebral palsy
- B. Hydrocephalus
- C. Meningitis
- D. Neuroblastoma
Correct answer: B
Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.
4. A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?
- A. Mild soap and water
- B. A cotton ball
- C. Mineral oil
- D. Alcohol swabs
Correct answer: C
Rationale: To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (Choice A) may not be effective in completely removing zinc oxide. A cotton ball (Choice B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (Choice D) can be harsh on the skin and are not recommended for this purpose.
5. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?
- A. Collect a urine specimen for culture analysis
- B. Review the client's fluid intake prior to bedtime
- C. Palpate the bladder above the symphysis pubis
- D. Obtain a fingerstick glucose level
Correct answer: C
Rationale: Palpating the bladder above the symphysis pubis is the most appropriate intervention in this scenario. It helps assess for urinary retention, which is a common issue in older males presenting with symptoms like difficulty starting urinary stream and feeling of incomplete bladder emptying. Collecting a urine specimen for culture analysis (Choice A) may be necessary in other situations like suspected urinary tract infection. Reviewing the client's fluid intake (Choice B) is important but does not directly address the current issue of urinary retention. Obtaining a fingerstick glucose level (Choice D) is not relevant to the client's urinary symptoms.
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