HESI LPN
Medical Surgical HESI 2023 Questions
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via a nasal cannula. Which assessment finding indicates a potential complication of oxygen therapy?
Correct Answer: B
Rationale: In clients with COPD, oxygen therapy can lead to a decrease in the respiratory drive caused by the removal of the hypoxic drive. This can result in carbon dioxide retention, leading to a decreased level of consciousness. Options A, C, and D are incorrect because an increased respiratory rate is typically a sign of hypoxia, improved oxygen saturation is a positive response to oxygen therapy, and complaints of dry mouth are not directly related to oxygen therapy complications in this scenario.
Question 2 of 5
A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?
Correct Answer: D
Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (
Choice
A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (
Choice
B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (
Choice
C) is unnecessary and could introduce contaminants into the drain.
Question 3 of 5
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
Correct Answer: A
Rationale: Corrected
Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
Question 4 of 5
A client with a history of seizures is prescribed phenytoin. Which instruction should the nurse include in the discharge teaching?
Correct Answer: A
Rationale: The correct answer is A: 'Report any signs of a sore throat or fever immediately.' Phenytoin can cause blood dyscrasias, which can manifest as a sore throat or fever. These symptoms could indicate a serious side effect that requires immediate medical attention.
Choice B is incorrect because phenytoin should not be taken with antacids as they can decrease its absorption.
Choice C is incorrect because discontinuing phenytoin abruptly can lead to rebound seizures; drowsiness is a common side effect that may improve with time.
Choice D is incorrect because adjusting the dosage of phenytoin should only be done under healthcare provider supervision, not based on experiencing an aura.
Question 5 of 5
A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump?
Correct Answer: C
Rationale:
To infuse 100 mL in 45 minutes, the infusion rate should be set to 133 mL/hour (100 mL / 0.75 hours). This calculation is obtained by dividing the total volume to be infused by the total time for infusion (100 mL / 0.75 hours = 133 mL/hour).
Therefore, choice C is the correct answer.
Choices A, B, and D are incorrect because they do not accurately calculate the infusion rate required to deliver the medication within the specified time frame.