a 2 month old infant has both a cleft lip and palate which will be repaired in stages in the immediate postoperative period for a cleft lip repair whi
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Nursing Elites

HESI LPN

Community Health HESI Test Bank 2023

1. In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?

Correct answer: A

Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.

2. Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

Correct answer: A

Rationale: Sports and games with rules are appropriate for the cognitive development stage of 7-year-olds.

3. A client with acute pancreatitis is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which of the following complications?

Correct answer: C

Rationale: The correct answer is C: Hyperglycemia. Total parenteral nutrition (TPN) contains a high glucose content, which can lead to elevated blood sugar levels, resulting in hyperglycemia. Monitoring for hyperglycemia is crucial in clients receiving TPN to prevent complications such as osmotic diuresis, dehydration, and electrolyte imbalances. Choices A, B, and D are incorrect because TPN is more likely to cause hyperglycemia rather than hypoglycemia, hyperkalemia, or hyponatremia.

4. The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?

Correct answer: D

Rationale: The correct answer is D, smoking cessation. Smoking is a major and modifiable risk factor for cardiovascular disease. It is often the highest priority in cardiac risk reduction because stopping smoking has immediate and long-term benefits for heart health. Choices A, B, and C are also important in reducing cardiac risk factors, but smoking cessation takes precedence due to its significant impact on cardiovascular health.

5. The nurse manager has a nurse employee who is suspected of having a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?

Correct answer: C

Rationale: Consulting with human resources is the best approach in this situation. It ensures that the issue is handled according to the organization's policies and that the nurse receives the appropriate support and intervention needed for chemical dependency. Confronting the nurse directly may lead to defensiveness and hinder a constructive resolution. Scheduling a staff conference without the nurse present can create unnecessary speculation and violate the employee's privacy. Counseling the employee to resign is not appropriate and does not address the underlying problem of chemical dependency.

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