HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?
- A. Administer the analgesic as requested.
- B. Request a pain assessment from another nurse.
- C. Ask the client to describe the pain more precisely.
- D. Delay administration until the pain is better described.
Correct answer: D
Rationale: The correct action for the nurse to implement next is to delay administration until the pain is better described. It is essential to have a clear understanding of the nature and location of the pain before administering any analgesic to ensure appropriate and effective pain management. Requesting a pain assessment from another nurse or asking the client to describe the pain more precisely would also be appropriate actions to obtain more information before administering the analgesic. Administering the analgesic as requested without a clear description of the pain may not address the client's needs effectively and could potentially lead to ineffective pain management.
2. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?
- A. Excessive growth
- B. Cognitive impairment
- C. Damage to the nervous system
- D. Damage to the urinary system
Correct answer: B
Rationale: The correct answer is B: Cognitive impairment. The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. Excessive growth (Choice A) is not a common complication of hypothyroidism in infants. Damage to the nervous system (Choice C) and damage to the urinary system (Choice D) are not typically associated with untreated hypothyroidism in infants.
3. The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?
- A. Administer the first dose of antibiotics.
- B. Obtain a chest X-ray.
- C. Administer oxygen therapy.
- D. Collect blood specimens for culture prior to starting antibiotic therapy.
Correct answer: D
Rationale: Collecting blood specimens for culture prior to starting antibiotic therapy is the priority intervention in a client diagnosed with hospital-acquired pneumonia. This step is crucial to identify the causative organism responsible for the infection and ensure that the antibiotics prescribed are appropriate for effective treatment. Administering antibiotics before collecting cultures may interfere with the accuracy of culture results, potentially leading to inappropriate treatment. While administering the first dose of antibiotics is important, obtaining a chest X-ray and administering oxygen therapy are secondary interventions compared to identifying the causative organism through blood cultures.
4. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct answer: B
Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.
5. A client with chronic kidney disease is advised to follow a low-phosphorus diet. Which food should the client avoid?
- A. Milk
- B. Apples
- C. Carrots
- D. Rice
Correct answer: A
Rationale: Correct Answer: Milk. Milk is high in phosphorus and should be avoided in a low-phosphorus diet for clients with chronic kidney disease. Choice B (Apples), C (Carrots), and D (Rice) are not significant sources of phosphorus and can be included in moderation in a low-phosphorus diet. Apples and carrots are generally considered healthy choices for most individuals, while rice is a staple food that is low in phosphorus and can be part of a renal diet.
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