HESI LPN
HESI Test Bank Medical Surgical Nursing
1. While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?
- A. Neutrophil count.
- B. Hematocrit.
- C. Blood pH.
- D. Serum potassium and sodium.
Correct answer: A
Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.
2. What is the main focus of secondary prevention?
- A. Early detection and treatment
- B. Rehabilitation
- C. Health promotion
- D. Palliative care
Correct answer: A
Rationale: The main focus of secondary prevention is early detection and treatment of disease. This approach aims to identify health conditions in their early stages when they are easier to treat or manage effectively. Choice B, rehabilitation, is more aligned with restoring function after an illness or injury has occurred. Choice C, health promotion, concentrates on educating and empowering individuals to adopt healthy behaviors to prevent the onset of diseases. Choice D, palliative care, is focused on providing comfort and improving the quality of life for individuals with serious illnesses or at the end of life, rather than on early detection and treatment.
3. A client with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. The nurse should instruct the client to report which potential side effect?
- A. Dry mouth
- B. Blurred vision
- C. Nausea
- D. Tachycardia
Correct answer: A
Rationale: The correct answer is A: Dry mouth. Tiotropium, a commonly prescribed medication for COPD, can cause dry mouth as a side effect. While it may not be severe, clients should report it if it becomes bothersome. Dry mouth is a common side effect of tiotropium due to its anticholinergic properties. Blurred vision, nausea, and tachycardia are not typically associated with tiotropium use in the context of COPD.
4. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment?
- A. Threats to kill his friend.
- B. Disruptive behaviors in a community setting.
- C. Hears voices telling him to kill himself.
- D. Reports he has not needed a bath in 4 months.
Correct answer: D
Rationale: The client's dangerous and disruptive behaviors, along with auditory hallucinations of self-harm, suggest a need for involuntary commitment for his safety and that of others. Involuntary commitment may be warranted based on the client's poor hygiene and self-neglect, as it indicates an inability to care for himself, which can pose a risk to his well-being.
5. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?
- A. Protect the client's feet from injury
- B. Apply a heating pad to affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct answer: A
Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.