HESI LPN
HESI Test Bank Medical Surgical Nursing Questions
Question 1 of 5
Which is a long-term complication of cleft lip and palate?
Correct Answer: C
Rationale: The correct answer is C, 'Faulty dentition.' The older child with cleft lip and palate may experience psychological difficulties due to the cosmetic appearance of the defect, issues with impaired speech, and faulty dentition. This can lead to problems with dental alignment, crowding, missing or malformed teeth, and other dental issues.
Choices A, B, and D are incorrect as cognitive impairment, altered growth and development, and physical abilities are not typically considered long-term complications of cleft lip and palate.
Question 2 of 5
The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?
Correct Answer: D
Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (
Choice
A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (
Choice
B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (
Choice
C) is a general intervention that may not directly address the specific concern of the low temperature reading.
Question 3 of 5
An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
Correct Answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (
Choice
A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (
Choice
C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (
Choice
D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
Question 4 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 5 of 5
What is the most critical initial intervention for a client who is actively seizing?
Correct Answer: C
Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (
Choice
A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (
Choice
B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (
Choice
D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.