HESI LPN
Medical Surgical HESI 2023
1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?
- A. Obtain a wound specimen for culture.
- B. Initiate an infusion of intravenous (IV) fluids.
- C. Transfer the client to the ICU.
- D. Assess the client's core temperature.
Correct answer: B
Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.
2. An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?
- A. Capillary refill takes > 3 seconds.
- B. Episodes of vertigo and loss of balance.
- C. Average daily output of 1200 ml.
- D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct answer: D
Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy. Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.
3. Parents of a school-age child ask the nurse for suggestions in helping the child who is demonstrating school avoidance. What is an appropriate suggestion by the nurse?
- A. Take the child to the healthcare provider for testing.
- B. Be firm and insist the child go to school.
- C. Allow the child to stay home and rest.
- D. Consult with the teacher at school.
Correct answer: B
Rationale: When a child is demonstrating school avoidance, it is important for parents to be firm and insist that the child go to school. This helps establish a routine and prevents the behavior from becoming a pattern. Taking the child to the healthcare provider for testing (Choice A) may not be necessary at this stage as school avoidance is a behavioral issue. Allowing the child to stay home and rest (Choice C) may reinforce the avoidance behavior. While consulting with the teacher at school (Choice D) is important, the immediate focus should be on addressing the avoidance behavior at home.
4. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to what volume of fluid?
- A. Two liters.
- B. Three liters.
- C. Four liters.
- D. Five liters.
Correct answer: B
Rationale: A weight gain of 6.6 pounds is approximately equivalent to 3 liters of fluid. It is important to remember that 1 liter of fluid is equal to 1 kg, which is approximately 2.2 pounds. Therefore, when the client gains 6.6 pounds, it translates to 3 liters of fluid. Choices A, C, and D are incorrect as they do not align with the conversion rate of 1 liter of fluid to 2.2 pounds.
5. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?
- A. Broccoli
- B. Chicken breast
- C. White bread
- D. Apple
Correct answer: A
Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.
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