HESI LPN
Community Health HESI Exam
1. When assessing a child with acute respiratory infection, what nursing intervention(s) would be appropriate?
- A. Provide safe remedies to relieve the child's sore throat and cough
- B. All of these interventions
- C. Advise the mother to monitor for signs of pneumonia
- D. Ensure proper nutrition to prevent weight loss
Correct answer: B
Rationale: In the management of acute respiratory infection in a child, it is essential to address various aspects of care. Providing safe remedies to relieve symptoms like sore throat and cough (Choice A) helps in managing discomfort. Advising the mother to monitor for signs of pneumonia (Choice C) is crucial for early detection and intervention if complications arise. Ensuring proper nutrition (Choice D) is important for the child's overall health and immune function during illness. Therefore, all the listed interventions are appropriate in managing acute respiratory infection, making Choice B the correct answer. Choices A, C, and D are incorrect on their own as they address only specific aspects of care and not the comprehensive management of acute respiratory infection.
2. A client with a diagnosis of generalized anxiety disorder is prescribed paroxetine. The nurse should instruct the client that this medication may have which potential side effect?
- A. Drowsiness
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: The correct answer is A: Drowsiness. Paroxetine, used for generalized anxiety disorder, can cause drowsiness. Clients should be advised not to drive or operate heavy machinery until they know how the medication affects them. Dry mouth, nausea, and headache are potential side effects of other medications but are not commonly associated with paroxetine. Drowsiness is a common side effect for paroxetine and can impact a client's ability to perform tasks that require alertness.
3. What is the most important action for preventing infection in a client with a central venous catheter?
- A. Changing the catheter dressing every 72 hours.
- B. Flushing the catheter with heparin solution daily.
- C. Ensuring the catheter is clamped when not in use.
- D. Maintaining sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.
4. Which observation of the exposed abdomen is most indicative of pyloric stenosis?
- A. abdominal rigidity
- B. substernal retraction
- C. palpable olive-like mass
- D. marked distention of the lower abdomen
Correct answer: C
Rationale: In pyloric stenosis, a palpable olive-like mass in the abdomen is a classic finding. This mass is due to the hypertrophied pyloric muscle. Abdominal rigidity (choice A) is associated with conditions like peritonitis, substernal retraction (choice B) is typically seen in respiratory distress, and marked distention of the lower abdomen (choice D) is more characteristic of conditions like intestinal obstruction rather than pyloric stenosis.
5. During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?
- A. Red, raised hair follicles
- B. Warmth at skin disruption site
- C. Papules progressing to vesicles
- D. Honey-colored exudate
Correct answer: B
Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.