HESI LPN
HESI Fundamentals Exam
1. 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.
2. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?
- A. Change the catheter every 72 hours.
- B. Ensure the catheter tubing is free of kinks.
- C. Clean the perineal area with antiseptic solution daily.
- D. Irrigate the catheter with normal saline every shift.
Correct answer: B
Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.
3. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?
- A. Perform a bladder scan to assess for urinary retention.
- B. Encourage the client to drink fluids.
- C. Insert a straight catheter to drain the bladder.
- D. Administer a diuretic as prescribed.
Correct answer: A
Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.
4. Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?
- A. “I will make sure the menu includes halal options.”
- B. “I will ask the client if they want to schedule prayer times during the day.”
- C. “I will avoid discussing care when the client’s family is around.”
- D. “I will make sure daily communion is available for this client.”
Correct answer: B
Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.
5. A healthcare professional is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the healthcare professional use first?
- A. Inspection
- B. Palpation
- C. Auscultation
- D. Percussion
Correct answer: A
Rationale: Inspection is the initial step in abdominal assessment as it allows the healthcare professional to visually observe any abnormalities or signs of bloating. Palpation, auscultation, and percussion are subsequent assessment techniques that follow inspection. Palpation involves feeling for tenderness, masses, or organ enlargement; auscultation is listening for bowel sounds; and percussion is used to assess the density of underlying tissues or detect the presence of fluid or air in the abdomen. In the context of a client reporting bloating, the first step should be visual inspection to gather initial information. Palpation, auscultation, and percussion come after inspection to provide a more comprehensive assessment.
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