HESI LPN
HESI Test Bank Medical Surgical Nursing
1. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?
- A. Neutralizes stomach acid
- B. Decreases gastric acid secretion
- C. Covers the ulcer site and protects it from acid
- D. Improves gastric motility
Correct answer: C
Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.
2. What is the most common method of attempted suicide?
- A. Hanging
- B. Drug overdose
- C. Gunshot
- D. Slashing the wrists
Correct answer: B
Rationale: Drug overdose is the most common method of attempted suicide. While hanging, gunshot, and slashing the wrists are also methods used in suicide attempts, statistics show that drug overdose is the most prevalent method chosen by individuals attempting suicide. Hanging, gunshot, and slashing the wrists are indeed common methods as well, but drug overdose ranks highest in terms of frequency.
3. A client with liver cirrhosis is at risk for developing hepatic encephalopathy. Which clinical manifestation should the nurse monitor for?
- A. Kussmaul respirations
- B. Asterixis (flapping tremor)
- C. Bradycardia
- D. Hypertension
Correct answer: B
Rationale: Corrected Rationale: Asterixis, also known as a flapping tremor, is a common sign of hepatic encephalopathy, indicating neurological dysfunction due to liver failure. Kussmaul respirations (option A) are associated with metabolic acidosis, which is not a typical manifestation of hepatic encephalopathy. Bradycardia (option C) and hypertension (option D) are not typically associated with hepatic encephalopathy; in fact, hepatic encephalopathy is more commonly associated with alterations in mental status, neuromuscular abnormalities, and changes in behavior.
4. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?
- A. Drowsiness
- B. Gingival hyperplasia
- C. Weight gain
- D. Blurred vision
Correct answer: B
Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.
5. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level.
- B. Encourage incentive spirometry.
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic.
Correct answer: D
Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.
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