HESI LPN
Medical Surgical Assignment Exam HESI
1. The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do your family members share combs and brushes?
- D. Do you have any dry patches on your feet and hands?
Correct answer: A
Rationale: The correct answer is A: 'Has everyone at home already had varicella?' Herpes zoster (shingles) is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. By knowing if others at home had varicella (chickenpox), the nurse can assess the risk of transmission and provide appropriate guidance. Choice B is incorrect because antifungal creams are not effective for herpes zoster, which is a viral infection. Choice C is irrelevant to herpes zoster as it pertains to sharing personal items that may transmit head lice or certain skin infections. Choice D is also unrelated as it focuses on dry patches, not typical manifestations of herpes zoster which presents as a painful rash.
2. A client with COPD is receiving home oxygen therapy. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Increase oxygen flow rate during physical activity
- B. Smoke at least 10 feet away from the oxygen source
- C. Use petroleum jelly to prevent nasal dryness
- D. Ensure the oxygen tank is stored in a secure upright position
Correct answer: D
Rationale: The most important instruction for the nurse to include in the discharge teaching for a client with COPD receiving home oxygen therapy is to ensure the oxygen tank is stored in a secure upright position. This is crucial to prevent accidents such as leaks or falls that can lead to serious injury or damage. Choice A is incorrect as increasing the oxygen flow rate during physical activity without a healthcare provider's guidance can be harmful. Choice B is incorrect as smoking near an oxygen source can cause a fire hazard. Choice C is incorrect as petroleum jelly is flammable and should not be used around oxygen due to the risk of combustion.
3. A client is receiving intravenous potassium chloride for hypokalemia. Which action should the nurse take to prevent complications during the infusion?
- A. Administer the infusion rapidly
- B. Monitor the infusion site for signs of infiltration
- C. Use a syringe pump for the infusion
- D. Flush the IV line with normal saline before starting the infusion
Correct answer: B
Rationale: The correct action to prevent complications during the infusion of potassium chloride is to monitor the infusion site for signs of infiltration. Rapid administration can lead to adverse effects, including cardiac arrhythmias. Using a syringe pump is not typically necessary for this infusion. Flushing the IV line with normal saline is a good practice but not directly related to preventing complications specifically during the infusion of potassium chloride.
4. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
- A. Document the client's report of pain in the electronic medical record.
- B. Determine which prescription will have the quickest onset of action.
- C. Compare the client's pain scale rating with the prescribed dosing.
- D. Ask the client to choose which medication is needed for the pain.
Correct answer: C
Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.
5. 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.
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