HESI LPN
Community Health HESI Questions
1. The nurse should consider the following when assessing the child for chest indrawing EXCEPT:
- A. Chest indrawing should be present at all times
- B. The lower chest wall does not go in when the child breathes in
- C. The lower chest goes in when the child breathes in
- D. The child should be calm
Correct answer: A
Rationale: The correct answer is A. Chest indrawing may not always be present and can vary with the child's activity level, so it should not be expected to be present at all times. Choice B is correct because the lower chest wall should not go in when the child breathes in. Choice C is correct as the lower chest should go in when the child breathes in, indicating chest indrawing. Choice D is correct as a calm child makes it easier to assess chest indrawing, but the absence of chest indrawing does not mean the child is not calm.
2. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated sed rate
- D. Increased glucose
Correct answer: A
Rationale: High protein levels in the cerebrospinal fluid are indicative of bacterial meningitis, as the presence of bacteria in the CSF leads to increased protein production. Elevated protein levels can be seen in inflammatory conditions like meningitis. Choice B, clear color, is not expected in meningitis as it is typically associated with cloudy or turbid CSF. Elevated sed rate (choice C) and increased glucose (choice D) are not typically associated with the laboratory findings seen in meningitis.
3. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to:
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist the client to turn, deep breathe, and cough
- D. Monitor oxygen saturation
Correct answer: B
Rationale: After a segmental lung resection, the priority nursing action should be to suction excessive tracheobronchial secretions. This helps in preventing airway obstruction from secretions, ensuring the patency of the airway and optimizing respiratory function. Administering pain medication can be important but addressing airway clearance takes precedence. Assisting the client to turn, deep breathe, and cough is essential for respiratory hygiene but not the first action immediately post-op. Monitoring oxygen saturation is crucial, but ensuring airway clearance is the priority to prevent complications.
4. A client with tuberculosis is receiving isoniazid (INH). The nurse should monitor the client for which of the following side effects?
- A. Hepatotoxicity
- B. Hyperglycemia
- C. Hypotension
- D. Hypokalemia
Correct answer: A
Rationale: The correct answer is A: Hepatotoxicity. Isoniazid (INH) can lead to hepatotoxicity, necessitating the monitoring of liver function tests. This adverse effect is characterized by liver damage and dysfunction. Choices B, C, and D are incorrect because isoniazid is not typically associated with hyperglycemia, hypotension, or hypokalemia. Therefore, the nurse should focus on assessing for signs and symptoms of hepatotoxicity in a client receiving isoniazid.
5. Which of these clients would the triage nurse request the healthcare provider to examine immediately?
- A. A 5-month-old infant with audible wheezing and grunting
- B. An adolescent with soot on the face and shirt
- C. A middle-aged man with second-degree burns on the right hand
- D. A toddler with singed ends of long hair extending to the waist
Correct answer: A
Rationale: The correct answer is A. Audible wheezing and grunting in an infant indicate respiratory distress, which is a critical condition requiring immediate assessment and intervention by the healthcare provider. Choices B, C, and D do not present with immediate life-threatening conditions that require urgent evaluation. Soot on the face and shirt, second-degree burns on the hand, and singed hair, while concerning, do not pose an immediate threat to life compared to respiratory distress in an infant.
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