HESI LPN
HESI Fundamentals Exam
1. In an emergency department, a nurse is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?
- A. Auscultate bowel sounds.
- B. Administer an antiemetic.
- C. Offer pain medication.
- D. Palpate the abdomen.
Correct answer: A
Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.
2. A client who is postoperative has paralytic ileus. Which of the following abdominal assessments should the nurse expect?
- A. Absent bowel sounds with distention
- B. Hyperactive bowel sounds with pain
- C. Normal bowel sounds with cramping
- D. Diminished bowel sounds with tenderness
Correct answer: A
Rationale: Paralytic ileus is a condition where there is a temporary paralysis of the bowel, leading to absent bowel sounds and abdominal distention. This occurs because the bowel is not functioning properly to propel contents, resulting in a lack of bowel sounds. Absent bowel sounds with distention are typical findings in paralytic ileus. Hyperactive bowel sounds with pain are more indicative of increased motility and are not expected in paralytic ileus. Normal bowel sounds with cramping may be seen in other conditions, such as gastroenteritis. Diminished bowel sounds with tenderness are not typical findings in paralytic ileus.
3. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?
- A. Arm
- B. Hip
- C. Back
- D. Ankle
Correct answer: C
Rationale: The correct answer is C: Back. Back injuries are common among healthcare workers, especially nurses, due to improper lifting techniques and bending. Working on an orthopedic rehabilitation unit involves frequent lifting and positioning of patients, putting the nurse at risk of back injuries. Preventing back injuries is crucial for maintaining the nurse's health and ability to provide care effectively. Choices A, B, and D are incorrect because while lifting and positioning patients may involve these body parts, back injuries are most likely to occur due to the strain and stress placed on the back during such activities.
4. The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?
- A. Blood pressure of 150/90 mmHg
- B. Irregular heart rhythm
- C. Shortness of breath
- D. Fatigue
Correct answer: C
Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.
5. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?
- A. Fluid volume deficit
- B. Altered nutrition: less than body requirements
- C. Anxiety related to new situational crisis
- D. Activity intolerance related to fatigue
Correct answer: A
Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99