HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. The nurse is caring for a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD). What is the most important intervention for the nurse?
- A. Help the child enroll in a special education class.
- B. Allay any feelings of guilt the parents may have.
- C. Explain to the parents that medications are lifelong.
- D. Teach the parents how to set limits.
Correct answer: B
Rationale: The most important intervention for the nurse in caring for a child with ADHD is to allay any feelings of guilt the parents may have. Parents of children with ADHD often experience guilt or self-blame, thinking they are responsible for their child's condition. By addressing and alleviating these feelings, the nurse can support the parents in a crucial way. Choice A is not the most important intervention because enrolling the child in a special education class might be a consideration but does not address the emotional needs of the parents. Choice C is incorrect because stating that medications are lifelong may cause unnecessary distress to the parents. Choice D is also not the most important intervention as setting limits is important but not as critical as addressing parental guilt and emotions.
2. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site.
- A. Ensure the client is NPO and document the last meal.
- B. Administer pain medication as prescribed.
- C. Apply a sterile dressing to the wound site.
- D. Notify the healthcare provider of the client’s medication history.
Correct answer: D
Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.
3. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. An old friend with eczema came for a visit.
- B. Recently received an influenza immunization.
- C. A grandson and his new dog recently visited.
- D. Corticosteroid cream was applied to eczema.
Correct answer: C
Rationale: The correct answer is C. Contact with the grandson's new dog could have introduced new allergens or irritants, exacerbating the eczema symptoms. Choice A is unrelated to the exacerbation of symptoms. Choice B, receiving an influenza immunization, is unlikely to directly cause an exacerbation of eczema symptoms. Choice D, applying corticosteroid cream, is a common treatment for eczema and would not likely be the cause of the exacerbation.
4. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
5. 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.
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