HESI LPN
Medical Surgical HESI Questions
Question 1 of 5
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?
Correct Answer: D
Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.
Question 2 of 5
When performing an assessment of a child with recurrent abdominal pain (RAP), what symptom is the child most likely to experience?
Correct Answer: B
Rationale: When assessing a child with recurrent abdominal pain (RAP), constipation is a common symptom. Children with RAP often experience periumbilical pain that is unrelated to eating, defecation, or exercise. While increased temperature, right quadrant pain, and exercise-associated pain can occur in various conditions, they are not typically associated with RAP in children.
Question 3 of 5
How is gastroesophageal reflux (GER) typically treated in infants?
Correct Answer: B
Rationale: Gastroesophageal reflux (GER) in infants is typically treated by thickening the formula or breast milk with cereal. This helps reduce reflux episodes by making the feedings heavier and less likely to come back up. Placing the infant NPO (nothing by mouth) is not the typical treatment for GER as infants need proper nutrition for growth. Placing the infant to sleep on the side is not recommended due to the risk of SIDS; infants should be placed on their back to sleep. Switching the infant to cow's milk is also not a treatment for GER, as cow's milk can be harder to digest and may exacerbate symptoms.
Question 4 of 5
Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?
Correct Answer: B
Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (
Choice
A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (
Choice
C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (
Choice
D) is not effective for a client with visual impairments.
Question 5 of 5
To assess the quality of an adult client's pain, what approach should the nurse use?
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.