HESI LPN
HESI Fundamentals Exam
1. 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.
2. A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?
- A. Loss of reflexes in the legs
- B. Decreased peripheral sensation
- C. Respiratory distress
- D. Muscle weakness in the arms
Correct answer: C
Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.
3. How should the nurse transcribe the dosage of this medication on the client's medical record?
- A. 0.3 mg
- B. 0.3 mg
- C. 0.30 mg
- D. 3/10 mg
Correct answer: B
Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.
4. When developing a plan of care for a client with dementia, what should the LPN/LVN remember about confusion in the elderly?
- A. It is not a normal part of aging.
- B. It often follows relocation to new surroundings.
- C. It is primarily due to changes in the brain associated with the disease.
- D. It cannot be prevented or cured by adequate sleep alone.
Correct answer: B
Rationale: When caring for a client with dementia, it is crucial to understand that confusion often arises after relocating to new surroundings. This change can disrupt familiar routines and trigger increased disorientation and confusion. Choice A is correct because confusion in the elderly is not a normal part of aging. Choice C is incorrect because confusion in dementia is primarily due to changes in the brain associated with the disease, not just irreversible brain pathology. Choice D is incorrect because while adequate sleep is important for overall health, it alone cannot prevent or cure confusion associated with dementia.
5. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?
- A. Place the bladder of the cuff over the posterior aspect of the thigh
- B. Use a smaller cuff designed for lower extremities
- C. Place the cuff around the client's ankle
- D. Ensure the cuff is positioned above the knee
Correct answer: A
Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.
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