HESI LPN
HESI Fundamentals Exam
1. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the client to practice deep breathing exercises.
- C. Position the client in high Fowler's position.
- D. Obtain a peak flow reading.
Correct answer: A
Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.
2. A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:
- A. Limit milk and milk products
- B. Encourage bed rest and quiet activities
- C. Plan nursing care around lengthy rest periods
- D. Promote a diet rich in iron
Correct answer: C
Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.
3. The healthcare provider is preparing a client with deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO prior to the test
- B. Client should receive a sedative medication before the test
- C. Discontinue anticoagulant therapy before the test
- D. No special preparation is necessary
Correct answer: D
Rationale: No special preparation is required for a Venous Doppler evaluation. Option A is incorrect because there is no need for the client to be NPO (nothing by mouth) before this test. Option B is incorrect as sedative medication is not typically administered for a Venous Doppler evaluation. Option C is incorrect as discontinuing anticoagulant therapy before the test may not be safe for a client with DVT, as it could increase the risk of developing a blood clot. Therefore, the correct answer is D.
4. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glascow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glascow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.
5. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?
- A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
- B. Ensure that the UAP has placed pillows effectively to protect the client
- C. Ask the UAP to use some pillows to prop the client in a side-lying position
- D. Assume responsibility for placing the pillows while the UAP completes another task
Correct answer: A
Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.
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