HESI LPN
Fundamentals of Nursing HESI
1. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:
- A. Check to see if the tubing is kinked.
- B. Increase the IV fluid rate.
- C. Check the catheter insertion site.
- D. Contact the healthcare provider.
Correct answer: A
Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.
2. A client with a history of alcoholism is admitted with confusion and ataxia. The LPN/LVN recognizes that these symptoms may be related to a deficiency in which vitamin?
- A. Vitamin A
- B. Vitamin C
- C. Vitamin D
- D. Vitamin B1 (Thiamine)
Correct answer: D
Rationale: The correct answer is Vitamin B1 (Thiamine). Vitamin B1 deficiency, also known as Thiamine deficiency, is common in clients with a history of alcoholism. Thiamine is essential for proper brain function, and its deficiency can lead to neurological symptoms such as confusion and ataxia. Vitamin A, C, and D deficiencies do not typically present with confusion and ataxia in the context of alcoholism. Vitamin A deficiency mainly affects vision, Vitamin C deficiency leads to scurvy with symptoms like bleeding gums, and Vitamin D deficiency is associated with bone disorders. Therefore, they are not the correct choices in this scenario.
3. A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?
- A. Use proper medical terms when providing instructions to the client.
- B. Offer written instructions in the client’s language.
- C. Direct verbal discharge instructions to the interpreter.
- D. Request that an assistive personnel interpret instructions for the client.
Correct answer: B
Rationale: The correct action for the healthcare provider when providing discharge teaching to a client who does not speak the same language is to offer written instructions in the client’s language. This approach helps ensure better comprehension and adherence to the instructions as the client can refer back to the written material for clarification. Choice A is incorrect because using proper medical terms may not be effective if the client does not understand the language. Choice C is incorrect since verbal instructions should be directed to the client for better understanding. Choice D is incorrect as assistive personnel may not be qualified or trained to provide accurate interpretation, risking miscommunication and potential errors in the instructions.
4. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?
- A. Avoid standing up too quickly.
- B. Increase fluid intake to stay hydrated.
- C. Eat more salt to help retain fluids.
- D. Wear compression stockings during the day.
Correct answer: A
Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.
5. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?
- A. Prolonged use does not typically cause dark concentrated urine.
- B. It is not necessary to take the medication on an empty stomach for optimal absorption.
- C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
- D. Drinking alcohol daily can cause drug-induced hepatitis.
Correct answer: D
Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.
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