HESI LPN
Medical Surgical Assignment Exam HESI Quizlet
1. What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most challenging aspect of care to implement?
- A. Forced fluids
- B. Increased feedings
- C. Bed rest
- D. Frequent position changes
Correct answer: C
Rationale: The correct answer is C: Bed rest. During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very challenging to implement with an active 6-year-old child. Forced fluids (choice A) may be necessary to maintain hydration. Increased feedings (choice B) may not be as difficult to implement as bed rest. Frequent position changes (choice D) may also be important but are not typically the most challenging aspect of care for a child with acute glomerulonephritis.
2. What should be included in the therapeutic management of iron deficiency anemia?
- A. Multivitamins
- B. Calcium
- C. Ferrous sulfate
- D. Iodine
Correct answer: C
Rationale: The correct answer is C: Ferrous sulfate. The therapeutic management of iron deficiency anemia should include iron supplementation, specifically with ferrous sulfate. This helps to replenish the body's iron stores. Multivitamins (choice A) may contain iron, but iron supplementation is more direct and effective. Calcium (choice B) and iodine (choice D) are not typically part of the primary treatment for iron deficiency anemia.
3. To assess the quality of an adult client’s pain, what approach should the nurse use?
- A. Ask the client to rate the pain on a scale of 1 to 10.
- B. Ask the client to describe the pain.
- C. Observe the client’s nonverbal cues.
- D. Determine the client’s pain tolerance.
Correct answer: B
Rationale: The correct approach for assessing the quality of an adult client's pain is to ask the client to describe the pain. By doing so, the nurse gains valuable information about the quality, location, and nature of the pain directly from the client. This approach allows for a more comprehensive understanding of the pain experience. Choice A, asking the client to rate the pain on a scale of 1 to 10, focuses more on intensity rather than quality. Choice C, observing the client's nonverbal cues, can provide additional information but may not fully capture the client's subjective experience of pain. Choice D, determining the client's pain tolerance, is not directly related to assessing the quality of pain but rather to how much pain a client can endure.
4. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femurs?
- A. Abduction
- B. Adduction
- C. Flexion
- D. Extension
Correct answer: A
Rationale: The correct answer is A: Abduction. The use of the Pavlik harness is to maintain the hips in abduction for 4 to 6 months to treat developmental hip dysplasia. This position helps in stabilizing the hip joint and promoting proper growth and development. Choices B, C, and D are incorrect because the Pavlik harness specifically aims to hold the child's femurs in abduction, not adduction, flexion, or extension.
5. The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?
- A. Avoid wearing compression stockings
- B. Elevate legs above heart level when resting
- C. Apply heat packs to improve circulation
- D. Limit walking to prevent leg pain
Correct answer: B
Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.
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