HESI LPN
Medical Surgical HESI Questions
Question 1 of 5
A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?
Correct Answer: D
Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.
Question 2 of 5
In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?
Correct Answer: B
Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.
Question 3 of 5
The nurse provides dietary instructions about iron-rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?
Correct Answer: B
Rationale: The correct answer is B: Oranges. Oranges are not a rich source of iron. Iron-rich foods include liver, leafy green vegetables, and kidney beans. Oranges are a good source of vitamin C but are not high in iron. Therefore, if the client selects oranges as an iron-rich food, it indicates a need for additional instructions on choosing foods high in iron.
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
Which dietary modification is most appropriate for a client with nephrotic syndrome?
Correct Answer: D
Rationale: The most appropriate dietary modification for a client with nephrotic syndrome is a low protein, low sodium diet. This diet helps reduce the workload on the kidneys and manage edema, which are common issues in nephrotic syndrome. Choice A, high protein, low sodium, is not recommended because excessive protein intake can further strain the kidneys. Choice B, low protein, high sodium, is inappropriate as high sodium can worsen fluid retention and hypertension. Choice C, high protein, high potassium, is not ideal as high potassium levels can be problematic for individuals with kidney issues.