HESI LPN
HESI Fundamentals Exam Test Bank
1. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
- A. A client who has a new diagnosis of adrenal insufficiency
- B. A client who has heart failure
- C. A client who is receiving treatment for diabetic ketoacidosis
- D. A client who has abdominal ascites
Correct answer: B
Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.
2. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?
- A. Decreased calcium
- B. Elevated potassium
- C. Increased sodium
- D. Low hemoglobin
Correct answer: A
Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.
3. A healthcare professional is teaching about home safety with a client. Which of the following instructions should the healthcare professional include?
- A. Unplug electronics by holding the plug
- B. Use electrical tape to secure extension cords next to baseboards on the floor
- C. To use a fire extinguisher, aim at the base of the flames
- D. Install slip-resistant rugs on tile floors
Correct answer: B
Rationale: The correct answer is to use electrical tape to secure extension cords next to baseboards on the floor. This practice helps prevent tripping and electrical hazards by keeping cords out of the way. Option A is incorrect as unplugging electronics should be done by holding the plug, not the cord itself. Option C is incorrect because when using a fire extinguisher, it should be aimed at the base of the flames, not at the top. Option D is not directly related to home safety teaching and may not be necessary for all clients, as it suggests an unnecessary change that may not improve safety.
4. The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct answer: B
Rationale: Irrigating the wound with sterile normal saline is the correct technique for cleansing a wound when the prescription does not specify a cleaning method. Sterile normal saline is a standard and safe solution that helps to remove debris and promote healing without damaging healthy tissue. Choice A, using povidone-iodine solution, can be cytotoxic and delay wound healing. Choice C, using hydrogen peroxide, can be cytotoxic, cause tissue damage, and delay wound healing. Choice D, using wet-to-dry dressing to remove eschar, is an outdated and non-selective method that can cause trauma to the wound bed and delay healing. Therefore, choice B is the best option for wound cleansing in this scenario.
5. A client is being taught how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will try to seal my lips around the mouthpiece
- B. I will use the spirometer as needed throughout the day
- C. I will inhale slowly and deeply when using the spirometer
- D. I will seal my lips around the mouthpiece
Correct answer: D
Rationale: The correct answer is D. Sealing the lips around the mouthpiece is crucial for the proper use of an incentive spirometer as it helps ensure effective delivery of the inhaled medication. Choice A has been corrected to reflect the importance of sealing the lips. Choices B and C are incorrect because using the spirometer as needed throughout the day and inhaling slowly and deeply, although beneficial, do not directly address the essential technique of sealing the lips around the mouthpiece.
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