HESI LPN
HESI Test Bank Medical Surgical Nursing
1. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
- A. Increase intake of high-fiber foods, such as bran cereal
- B. Restrict protein intake by limiting meats and other high-protein foods.
- C. Limit oral fluid intake to 500ml per day
- D. Increase intake of potassium-rich foods such as bananas and cantaloupe.
Correct answer: B
Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.
2. The parents of a child who has had a myringotomy are instructed by the nurse to place the child in which position?
- A. Supine
- B. On the affected side
- C. On the unaffected side
- D. In Trendelenburg's position
Correct answer: B
Rationale: Placing the child on the affected side after a myringotomy facilitates ear drainage. This position helps prevent accumulation of fluids in the ear canal, aiding in the healing process. Placing the child in the supine position (Choice A) or on the unaffected side (Choice C) may not be as effective in promoting drainage. The Trendelenburg's position (Choice D) with the head lower than the body is used for conditions requiring increased venous return, not for post-myringotomy care.
3. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- A. Nuchal rigidity
- B. Carotid bruit
- C. Jugular vein distention
- D. Palpable cervical lymph node
Correct answer: B
Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.
4. Which instruction should be included in the discharge teaching plan for a client who has had a cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment after applying eye drops.
- C. Light housekeeping is safe to do, but avoid heavy lifting.
- D. Refrain from sexual activities until follow-up appointment.
Correct answer: C
Rationale: The correct instruction to include in the discharge teaching plan for a client who has had a cataract extraction is that light housekeeping is safe to do, but heavy lifting should be avoided to prevent increased intraocular pressure. Choice A is incorrect as the eye shield is usually worn at night to protect the eye. Choice B is incorrect as eye ointment is usually applied after eye drops to avoid washing away the ointment. Choice D is incorrect as sexual activities should be avoided until the follow-up appointment to prevent complications.
5. 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.
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