HESI LPN

1. The nurse administers a booster dose of DTaP (diphtheria, tetanus, and pertussis) vaccine to an infant. Which level of prevention is the nurse implementing?

• A. Primary prevention.
• B. Tertiary prevention.
• C. Secondary prevention.
• D. Primary nursing.

Correct Answer: A

Rationale: The correct answer is A: Primary prevention. Administering a booster dose of DTaP vaccine to an infant is an example of primary prevention. Primary prevention aims to prevent disease or injury before it occurs by preventing exposure to risk factors. Tertiary prevention focuses on reducing the impact of a disease or injury that has already occurred, while secondary prevention involves early detection and treatment to prevent the progression of disease. Choice B, tertiary prevention, is incorrect as it deals with managing the consequences of a disease rather than preventing it. Choice C, secondary prevention, is also incorrect as it focuses on early detection and treatment rather than vaccination to prevent the disease. Choice D, primary nursing, is unrelated to the level of prevention being implemented in this scenario.

2. Which of the following is an example of a positive outcome for one of the Leading Health Indicators of Healthy People 2020?

• A. A community has adopted a no smoking policy.
• B. A rural community has a public transportation system.
• C. The high school dropout rate has decreased by 15%.
• D. A county has decreased its divorce rate by 10%.

Correct Answer: A

Rationale: The correct answer is A. A community adopting a no smoking policy is a positive outcome for the Leading Health Indicators of Healthy People 2020 as it promotes a healthier environment by reducing exposure to secondhand smoke and decreasing smoking-related illnesses. Choices B, C, and D do not directly align with the goals of the Leading Health Indicators. While public transportation and reduced dropout rates are beneficial for community well-being, they are not specific examples of Leading Health Indicators. Decreasing divorce rates, while potentially beneficial for family stability, is not a focus area of the Leading Health Indicators.

3. The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings?

• A. Refer the client to a nutritionist after providing health teaching about a low-sodium diet.
• B. Place the client in a recumbent position and call the paramedics for transport to the hospital.
• C. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service.
• D. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

Correct Answer: D

Rationale: The appropriate nursing action in response to significantly high blood pressure readings like 172/104 mm Hg and 164/98 mm Hg is to confirm the readings by taking the blood pressure in the other arm. This can help rule out any error or issue specific to that arm. The nurse should then schedule a healthcare practitioner's appointment for as soon as possible to further assess the client's condition and determine the appropriate intervention. Choice A is incorrect because solely referring the client to a nutritionist for a low-sodium diet without further assessment or confirmation of the blood pressure readings is premature. Choice B is incorrect as the client is already seated, and calling paramedics for immediate transport to the hospital is not warranted based solely on the blood pressure readings provided. Choice C is incorrect as stress may not be the sole reason for the high blood pressure readings, and further assessment is required before referring the client to counseling services.

4. Which individual has the highest risk of developing community-acquired pneumonia?

• A. A 40-year-old first-grade teacher who works with underprivileged children.
• B. A 75-year-old retired secretary with exercise-induced wheezing.
• C. A 60-year-old homeless person who is an alcoholic and smokes.
• D. A 35-year-old aerobics instructor who skips meals and eats only vegetables.

Correct Answer: C

Rationale: The correct answer is the 60-year-old homeless person who is an alcoholic and smokes. This individual has the highest risk of developing community-acquired pneumonia due to factors such as homelessness, alcoholism, and smoking, which weaken the immune system and make them more susceptible to respiratory infections. Choice A is incorrect as working with underprivileged children, while potentially exposing the individual to various illnesses, does not directly increase the risk of pneumonia. Choice B is less likely as exercise-induced wheezing may suggest asthma but does not directly correlate with pneumonia risk. Choice D, an aerobics instructor who eats only vegetables and skips meals, does not have the same level of risk factors for pneumonia as the homeless person in choice C.

5. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?

• A. 13 to 18 years of age.
• B. 11 to 12 years of age.
• C. 18 to 24 months of age.
• D. 4 to 6 years of age.

Correct Answer: D

Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.