HESI LPN
Medical Surgical Assignment Exam HESI Quizlet Questions
Question 1 of 5
A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?
Correct Answer: A
Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.
Question 2 of 5
A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea/vomiting. The examining healthcare provider believes that the client has experienced an acute myocardial infarction (AMI) within the past three hours and would like to initiate tissue plasminogen activator (tPA) therapy. Which client history findings contraindicate the use of tPA?
Correct Answer: B
Rationale: A history of cerebrovascular hemorrhage is a contraindication for tPA therapy due to the risk of bleeding.
Choice A is incorrect because treating hypoglycemia with an oral hypoglycemic agent is not a contraindication for tPA therapy.
Choice C is incorrect as age and family history of MI do not contraindicate the use of tPA.
Choice D is incorrect as being intolerant of medication containing aspirin is not a contraindication for tPA therapy.
Question 3 of 5
How often should the casts be changed for a newborn with talipes who is wearing casts?
Correct Answer: B
Rationale: The correct answer is B: Weekly. Treatment of talipes involves manipulation and applying short leg casts. The casts need to be changed weekly to allow for further manipulation and to accommodate the rapid growth of the infant. Changing the casts daily (choice
A) would be too frequent and may not provide enough time for the correction to take place. Changing the casts biweekly (choice
C) or monthly (choice
D) would not provide adequate support for the ongoing correction process required for talipes.
Question 4 of 5
A new mother asks the clinic nurse if she must continue giving her baby nystatin for thrush since the white lesions on his tongue have disappeared. What response by the nurse is most appropriate?
Correct Answer: B
Rationale: The correct answer is B because nystatin should be given for the full 7 days even if the lesions are no longer present. Continuing the treatment for the prescribed duration ensures complete eradication of the fungal infection.
Choice A is incorrect as stopping the medication prematurely may lead to the reoccurrence of thrush.
Choice C is inaccurate as nystatin is not just for comfort but for effective treatment.
Choice D is incorrect as refilling the medication for a second week without medical advice may lead to unnecessary prolonged use and potential side effects.
Question 5 of 5
A client is receiving intravenous potassium chloride for hypokalemia. Which action should the nurse take to prevent complications during 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.