HESI LPN
Medical Surgical Assignment Exam HESI Questions
Question 1 of 5
Which nursing intervention promotes achievement of the goal 'optimal mobility' for a client who had a total hip replacement 8 hours ago?
Correct Answer: D
Rationale: Assisting the client to turn while an abductor pillow is between the legs is the correct intervention to promote optimal mobility for a client who had a total hip replacement 8 hours ago. Using an abductor pillow helps maintain hip alignment and prevents dislocation, which are crucial considerations in the early postoperative period. Encouraging the client to use an abductor pillow when turning is more beneficial compared to the other options: teaching leg exercises in bed, encouraging the use of a walker when ambulating, or assisting the client to sit at the edge of the bed, as these interventions may not directly address the specific needs of a client after a total hip replacement.
Question 2 of 5
The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply)
Correct Answer: D
Rationale: The correct answer is D, as all the listed factors - abdominal obesity, high blood pressure, and increased triglyceride levels - are components of metabolic syndrome. Addressing these findings is crucial to help reduce the client's risk for developing diabetes mellitus and vascular disease. Abdominal obesity is a key feature of metabolic syndrome, high blood pressure (150/96 mmHg) is a risk factor, and increased triglyceride levels are also indicative of the syndrome. Educating the client on lifestyle modifications, such as healthy eating habits, regular physical activity, and monitoring these parameters, is essential in managing metabolic syndrome and preventing associated complications. Choices A, B, and C are all correct, making choice D the correct answer.
Question 3 of 5
The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.
Question 4 of 5
The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardic, restless, and irritable. Which action should the nurse take first?
Correct Answer: D
Rationale: In this scenario, the nurse should first check under the client for evidence of bleeding. A blood pressure of 98/40 mm Hg, along with tachycardia, restlessness, and irritability, could indicate internal hemorrhage following abdominal surgery. Checking for bleeding under the back is crucial to rule out this life-threatening complication. Notifying the healthcare provider, ensuring IV infusion, or listening to lung sounds can be important but are secondary to ruling out immediate life-threatening conditions like internal bleeding.
Question 5 of 5
A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.