HESI LPN
Leadership and Management HESI Quizlet
1. During which stage of anesthesia is a patient most likely to experience involuntary motor activity?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage VI
Correct answer: B
Rationale: The correct answer is Stage II. During Stage II of anesthesia, a patient is most likely to experience involuntary motor activity. This stage is known as the excitement stage, where the patient may exhibit purposeful or involuntary movements. Choice A (Stage I) is incorrect because Stage I is the induction phase where the patient is transitioning from consciousness to unconsciousness, and involuntary motor activity is less likely to occur. Choice C (Stage III) is incorrect as it is the stage of surgical anesthesia characterized by muscle relaxation, and involuntary motor activity is less common during this stage. Choice D (Stage VI) is incorrect as there is no Stage VI in the standard stages of anesthesia. Therefore, the most appropriate stage where involuntary motor activity is likely to occur is Stage II.
2. Your patient has a blood potassium level of 9.2 mEq/L. What intervention should you anticipate for this patient?
- A. Intravenous potassium supplementation
- B. Intravenous calcium supplementation
- C. Kidney dialysis
- D. Parenteral nutrition
Correct answer: C
Rationale: The correct answer is C: Kidney dialysis. A blood potassium level of 9.2 mEq/L indicates severe hyperkalemia, which can be life-threatening. Kidney dialysis is the most appropriate intervention to rapidly lower potassium levels in this situation. Choice A, intravenous potassium supplementation, would worsen the hyperkalemia. Choice B, intravenous calcium supplementation, is not the primary intervention for hyperkalemia. Choice D, parenteral nutrition, is unrelated to treating hyperkalemia and would not address the immediate concern.
3. A client is in DKA, secondary to infection. As the condition progresses, which of the following symptoms might the nurse see?
- A. Kussmaul's respirations and a fruity odor on the breath
- B. Shallow respirations and severe abdominal pain
- C. Decreased respirations and increased urine output
- D. Cheyne-Stokes respirations and foul-smelling urine
Correct answer: A
Rationale: In diabetic ketoacidosis (DKA), as the condition progresses, the body tries to compensate for the acidic environment by increasing the respiratory rate, leading to Kussmaul's respirations. The accumulation of ketones in the body causes a fruity odor on the breath. Option A is correct because Kussmaul's respirations and a fruity odor on the breath are classic signs of DKA. Option B is incorrect because shallow respirations are not typically seen in DKA, and severe abdominal pain is more commonly associated with conditions like pancreatitis. Option C is incorrect as decreased respirations are not a typical finding in DKA, and increased urine output is more commonly seen in conditions like diabetes insipidus. Option D is incorrect because Cheyne-Stokes respirations are not characteristic of DKA, and foul-smelling urine is not a prominent symptom in this condition.
4. The doctor has ordered 20 cc per hour of normal saline intravenously for your pediatric patient. You will be using pediatric intravenous tubing that delivers 60 cc per drop. How many drops per minute will you administer using this pediatric intravenous set?
- A. 30 drops per minute
- B. 25 drops per minute
- C. 20 drops per minute
- D. 22 drops per minute
Correct answer: C
Rationale: To calculate the drops per minute, first convert the ordered amount to drops per minute. 20 cc per hour equals 20 drops per hour with 60 cc per drop tubing, which is equivalent to 20 drops per hour * 60 cc per drop = 1200 drops per hour. To find drops per minute, divide 1200 by 60 (minutes in an hour), which equals 20 drops per minute. Therefore, the correct answer is 20 drops per minute. Choices A, B, and D are incorrect as they do not reflect the correct calculation based on the provided information.
5. A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who reports right-sided flank pain and is diaphoretic
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who has a raised red skin rash on his arms, neck, and face
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct answer: D
Rationale: The correct answer is D because shortness of breath with referred pain may indicate a serious condition, such as a cardiac event or pulmonary embolism, making this the highest priority. Option A, flank pain with diaphoresis, could suggest kidney-related issues but is not as immediately life-threatening as compromised breathing. Option B, active bleeding, though serious, can usually be controlled with proper interventions. Option C, a raised red skin rash, may indicate an allergic reaction but is not as urgent as respiratory distress with neck and shoulder pain.
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