HESI LPN
HESI Test Bank Medical Surgical Nursing Questions
Question 1 of 5
The nurse is providing discharge teaching for a client with heart failure. Which instruction should be included to prevent fluid overload?
Correct Answer: A
Rationale: The correct answer is A: 'Weigh yourself daily and report a gain of 2 pounds in 24 hours.' Daily weight monitoring is crucial for detecting fluid retention early in clients with heart failure. Reporting a gain of 2 pounds in 24 hours can indicate fluid overload, prompting timely intervention.
Choice B is incorrect because increasing fluid intake can exacerbate fluid overload in clients with heart failure.
Choice C is incorrect as a high-sodium diet can worsen fluid retention.
Choice D is incorrect as vigorous exercise can strain the heart and worsen heart failure symptoms.
Question 2 of 5
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?
Correct Answer: C
Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva.
Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination.
Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.
Question 3 of 5
While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.
Question 4 of 5
A client with a new colostomy is concerned about odor. What is the best advice the nurse can provide?
Correct Answer: B
Rationale: The best advice the nurse can provide to a client concerned about odor from a new colostomy is to use an odor-proof pouch. This option helps control odors effectively by containing and masking any unpleasant smells. Avoiding high-fiber foods (
Choice
A) is not the best advice as fiber is essential for bowel health, and decreasing fluid intake (
Choice
C) can lead to dehydration and other complications. Increasing dairy products in the diet (
Choice
D) is not directly related to controlling odors from a colostomy.
Question 5 of 5
A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?
Correct Answer: C
Rationale:
To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (
Choice
A) may not be effective in completely removing zinc oxide. A cotton ball (
Choice
B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (
Choice
D) can be harsh on the skin and are not recommended for this purpose.