HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Processed cheese
- C. Whole grain bread
- D. Fresh vegetables
Correct answer: B
Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.
2. The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?
- A. 50 ml/hour.
- B. 75 ml/hour.
- C. 100 ml/hour.
- D. 125 ml/hour.
Correct answer: C
Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.
3. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?
- A. Flush the tube with 50 mL of normal saline every 8 hours
- B. Clamp the tube when not in use
- C. Position the client in a supine position
- D. Verify tube placement by checking pH of gastric contents
Correct answer: D
Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.
4. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.
- A. Increase the room temperature.
- B. Assess the oxygen saturation.
- C. Continue to monitor vital signs.
- D. Notify the rapid response team.
Correct answer: D
Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.
5. A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?
- A. Pain
- B. Nocturia
- C. Dyspnea
- D. Frequent cough
Correct answer: A
Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.
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