Fundamentals HESI

HESI LPN

1. A client is receiving discharge teaching about a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

A. I should avoid foods high in potassium while taking this medication.
B. I will check my pulse before taking the medication.
C. I should avoid taking antacids simultaneously with this medication.
D. I will take the medication at the same time every day.

Correct answer: A

Rationale: The correct answer is A because clients taking digoxin should avoid foods high in potassium. High potassium levels can potentiate the effects of digoxin, leading to toxicity. Choices B, C, and D are correct statements regarding digoxin administration. Checking the pulse before taking the medication helps monitor for signs of digoxin toxicity. Avoiding taking antacids simultaneously prevents interactions that may reduce digoxin absorption. Taking the medication at the same time every day helps maintain a consistent blood level, ensuring optimal therapeutic effects.

2. When assessing a client's skin turgor, a nurse should:

A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
B. Check skin elasticity on the back of the hand
C. Press on the skin over the abdomen
D. Measure skin turgor on the lower leg

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

3. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

A. Folic acid should be taken before and after conception.
B. Multivitamin supplements are recommended during pregnancy.
C. A well-balanced diet promotes normal fetal development.
D. Increased dietary iron improves the health of mother and fetus.

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

4. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit, the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?

A. Dystonia
B. Akathisia
C. Bradykinesia
D. Tardive dyskinesia

Correct answer: D

Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a potential side effect of long-term antipsychotic use, characterized by involuntary movements like lip smacking and repetitive, purposeless movements. Choice A, dystonia, presents with sustained or repetitive muscle contractions. Choice B, akathisia, involves motor restlessness and a compelling need to be in constant motion. Choice C, bradykinesia, refers to slowness of movement typically seen in Parkinson's disease, not lip smacking and teeth grinding, which are indicative of tardive dyskinesia.

5. During a family assessment, a nurse is interviewing a family composed of a husband, a wife, and three children. One child is biological from this marriage, and the other two are from the wifeâ€™s previous marriage. How should the nurse identify this family form?

A. Extended
B. Blended
C. Nuclear
D. Alternative

Correct answer: B

Rationale: The correct answer is 'Blended.' This family is considered a blended family because it consists of children from previous marriages, along with the biological child of the current marriage. Choice A ('Extended') refers to a family that includes relatives beyond the nuclear family, such as grandparents or aunts/uncles. Choice C ('Nuclear') typically consists of a husband, wife, and their biological children only. Choice D ('Alternative') does not accurately describe the family structure presented in the scenario.