HESI LPN
HESI Fundamentals 2023 Test Bank
1. A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following techniques should the nurse identify as indicating the correct method for eliciting the client's patellar reflex?
- A. Tap just below the knee
- B. Tap on the upper thigh
- C. Tap on the ankle
- D. Tap on the lower leg
Correct answer: A
Rationale: The correct technique for eliciting the client's patellar reflex is to tap just below the knee. This action stimulates the stretch receptors in the patellar tendon, leading to a reflex contraction of the quadriceps muscle and extension of the lower leg. Tapping on the upper thigh (Choice B) would not elicit the patellar reflex as it targets a different area. Similarly, tapping on the ankle (Choice C) or tapping on the lower leg (Choice D) would not produce the desired response associated with the patellar reflex, making them incorrect choices.
2. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client’s wrists before applying the restraints
- B. Tie the restraints to the side rails of the bed
- C. Secure the restraints to the bed frame
- D. Use a quick-release knot to tie the restraints
Correct answer: A
Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.
3. A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
- A. We will determine who the durable power of attorney for health care form has designated.
- B. We will apply oxygen through a tube in your nose.
- C. We will ask if you have changed your mind.
- D. We will insert a breathing tube while we evaluate your condition.
Correct answer: B
Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.
4. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
- A. A client who has nasogastric suctioning
- B. A client who has chronic constipation
- C. A client who has syndrome of inappropriate antidiuretic hormone
- D. A client who took a toxic dose of sodium bicarbonate antacids
Correct answer: A
Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.
5. A middle-aged adult in a clinical setting mentions being at average risk for colon cancer and asks about routine screening. What should the nurse recommend?
- A. Performing a blood sample for a screening test.
- B. Scheduling a colonoscopy starting at age 60.
- C. Undergoing a fecal occult blood test annually.
- D. Having a sigmoidoscopy every 10 years.
Correct answer: C
Rationale: The correct answer is C. Colorectal cancer screening for individuals at average risk typically begins at age 50. One of the recommended options for routine screening is a fecal occult blood test done annually. Choice A is incorrect as blood samples are not used for routine colorectal cancer screening. Choice B is incorrect because colonoscopies usually start at age 50, not 60. Choice D is incorrect as sigmoidoscopies are recommended every 5 years, not every 10 years, for individuals at average risk for colon cancer.
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