HESI LPN
HESI Fundamentals Exam
1. A client is receiving teaching from a healthcare provider about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform ankle and knee exercises every hour - Range of motion (ROM) is needed to prevent contractures.
- B. I will hold my breath when rising from a sitting position.
- C. I will remove my antiembolic stockings while I am in bed.
- D. I will have my partner help me change positions every 4 hours.
Correct answer: A
Rationale: Choice A is correct because performing ankle and knee exercises every hour helps prevent contractures and other adverse effects of immobility. Contractures are a common complication of immobility, and range of motion (ROM) exercises can help maintain joint flexibility and prevent contractures. This statement indicates an understanding of the teaching provided by the healthcare provider. Choices B, C, and D are incorrect. Holding the breath when rising from a sitting position can increase the risk of orthostatic hypotension, not reduce adverse effects of immobility. Removing antiembolic stockings while in bed can compromise their effectiveness in preventing deep vein thrombosis (DVT), which is not a measure to reduce immobility-related complications. Having a partner help change positions every 4 hours may not be frequent enough to prevent immobility-related complications effectively; changing positions more frequently is usually recommended to prevent issues like pressure ulcers and muscle stiffness.
2. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?
- A. Teaching the client about the purpose of the medication
- B. Giving the medication at the administration time the provider prescribed
- C. Identifying the client’s medication allergies
- D. Documenting the client’s anxiety level
Correct answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.
3. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.
4. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
- A. Reposition the client
- B. Document the client's IV intake in the medical record
- C. Request a new IV fluid prescription
- D. Check the IV tubing for obstruction
Correct answer: D
Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.
5. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.
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