HESI LPN
HESI Fundamentals Exam Test Bank
1. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
- A. Swelling and redness in the affected leg
- B. Pain in the affected leg
- C. Warmth and tenderness in the affected leg
- D. A positive Homans' sign
Correct answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
2. The nurse is caring for a 4-year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?
- A. Vomiting of dark emesis
- B. Complaints of throat pain
- C. Apical heart rate of 110
- D. Increased restlessness
Correct answer: D
Rationale: Increased restlessness must be reported immediately as it may indicate bleeding or other complications post-tonsillectomy and adenoidectomy. This could be a sign of a developing issue that requires urgent intervention. Vomiting of dark emesis, complaints of throat pain, and an apical heart rate of 110 are important to monitor but do not indicate an immediate need for reporting as compared to the potential seriousness of increased restlessness in this scenario.
3. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?
- A. What is your daily calorie consumption?
- B. What vitamin and mineral supplements do you take?
- C. Do you feel that you are overweight?
- D. Will a clear liquid diet be okay after surgery?
Correct answer: B
Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.
4. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct answer: C
Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.
5. When caring for an older adult client who becomes agitated when asked to remove dentures before surgery, which of the following responses should the nurse make?
- A. "What worries you about being without your teeth?"
- B. "You need to follow the preoperative instructions and remove your dentures."
- C. "It's important to remove dentures to ensure proper fitting of the mask during anesthesia."
- D. "I will explain why dentures need to be removed before surgery."
Correct answer: A
Rationale: The correct response is to ask the client about their concerns regarding being without their teeth. This approach helps address the client's anxiety and provides insight into the reason for their agitation. Choice B is authoritarian and does not address the client's emotional needs. Choice C focuses on the technical aspect of surgery and does not address the client's emotional state. Choice D implies a one-way communication without addressing the client's feelings or concerns.
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