HESI LPN
Medical Surgical HESI
1. Following surgical repair of a cleft palate, what should be used to prevent injury to the suture line?
- A. Straw
- B. Spoon
- C. Syringe
- D. Cup
Correct answer: D
Rationale: Following surgical repair of a cleft palate, a cup should be used to prevent injury to the suture line. Utensils such as straws, spoons, droppers, and syringes should be avoided as they can cause trauma to the surgical site. Using a cup reduces the risk of disrupting the sutures and promotes proper healing.
2. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?
- A. Check the blood glucose level
- B. Administer insulin immediately
- C. Offer a high-protein snack
- D. Place the client in a supine position
Correct answer: A
Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.
3. 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.
4. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?
- A. Hypotension
- B. Tachycardia
- C. Severe headache
- D. Flushed skin below the level of injury
Correct answer: C
Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.
5. Which additional congenital malformation is expected in 80% of infants with a myelomeningocele?
- A. Cerebral palsy
- B. Hydrocephalus
- C. Meningitis
- D. Neuroblastoma
Correct answer: B
Rationale: Hydrocephalus is the additional congenital malformation expected in 80% of infants with a myelomeningocele. Myelomeningocele is commonly associated with hydrocephalus due to the abnormal accumulation of cerebrospinal fluid in the brain. Cerebral palsy (Choice A) is a motor disorder but not typically associated with myelomeningocele. Meningitis (Choice C) is an infection of the meninges and is not a congenital malformation. Neuroblastoma (Choice D) is a type of cancer that originates in immature nerve cells and is not a typical association with myelomeningocele.
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