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HESI LPN · HESI LPN Medical Surgical Nursing · Medical Surgical HESI 2023

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?

A. Palpate for abdominal distention

B. Send fluid to the lab for analysis

C. Continue to monitor the fluid output

D. Clamp the drainage tube for 5 minutes

Expert Explanatory Rationale

Correct Answer: Continue to monitor the fluid output

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?

A. Reinforce the incisional dressings and assess behind the neck for drainage.

B. Place the client in a right lateral side-lying position and elevate the head of the bed.

C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.

D. Compress the bulb with the tab open and then reinsert the tab into its opening.

Expert Explanatory Rationale

Correct Answer: Compress the bulb with the tab open and then reinsert the tab into its opening.

Question 3 of 5

A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?

A. Evaluate distal capillary refill for delayed perfusion

B. Check the extremities for bruising and petechiae

C. Examine the peritibial regions for pitting edema

D. Palpate the abdomen for tenderness and rigidity

Expert Explanatory Rationale

Correct Answer: Palpate the abdomen for tenderness and rigidity

Question 4 of 5

What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

A. A history of diarrhea following each feeding

B. Gastric pain evidenced by vigorous crying

C. Poor appetite due to a poor sucking reflex

D. An olive-shaped mass right of the midline

Expert Explanatory Rationale

Correct Answer: An olive-shaped mass right of the midline

Question 5 of 5

What is the priority patient problem for the parents of a newborn born with cleft lip and palate?

A. Parental role conflict

B. Risk for delayed growth and development

C. Risk for impaired attachment

D. Anticipatory grieving

Expert Explanatory Rationale

Correct Answer: Risk for impaired attachment

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