HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. Which laboratory results should the nurse anticipate to be abnormal in a child with hemophilia?
- A. Prothrombin time
- B. Bleeding time
- C. Platelet count
- D. Partial thromboplastin time
Correct answer: D
Rationale: In a child with hemophilia, the nurse should anticipate an abnormality in the partial thromboplastin time (PTT) due to the deficiency in clotting factors. Prothrombin time, bleeding time, and platelet count are typically normal in hemophilia. Prothrombin time measures the extrinsic pathway of coagulation and is not affected in hemophilia. Bleeding time assesses platelet function, which is normal in hemophilia as the issue lies with clotting proteins, not platelets. Platelet count is also expected to be normal unless there is another underlying condition affecting platelet production or function.
2. A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
- A. Insert an implanted port
- B. Close a laceration with sutures
- C. Place an endotracheal tube
- D. Initiate an enteral feeding through a gastrostomy tube
Correct answer: D
Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.
3. A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?
- A. Ankle-foot orthotic
- B. Continuous passive motion machine
- C. Abduction splint
- D. Sequential compression device
Correct answer: A
Rationale: An ankle-foot orthotic is the correct choice to prevent a plantar flexion contracture in a paralyzed limb. An ankle-foot orthotic helps maintain proper alignment of the foot and ankle, preventing the foot from being permanently fixed in a pointed-down position. Continuous passive motion machines are typically used to promote joint movement after surgery and would not address the prevention of contractures in this case. Abduction splints are used to keep the legs apart and would not address the specific issue described. Sequential compression devices are used to prevent deep vein thrombosis by promoting circulation in the lower extremities and are not indicated for preventing plantar flexion contractures.
4. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
- A. Contact the hospital’s spiritual services.
- B. Ask what is making the client cry.
- C. Ensure no visitors or staff enter the room for a short time period.
- D. Turn on the television for a distraction.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.
5. An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse’s attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct answer: D
Rationale: In this scenario, the best action for the nurse manager to take is to ask the nurses to meet with the nurse-manager to identify ways of working together. This approach promotes open communication, facilitates understanding of both perspectives, and encourages collaborative problem-solving. Option A is not ideal as involving a mental health consultant may be premature for this situation. Option B, although helpful in listening to both parties, does not directly address the need for collaboration. Option C focuses on the senior nurse's mentoring strategies only, rather than addressing the conflict between the two nurses.