HESI LPN
HESI Fundamentals Test Bank
1. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice, and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct answer: B
Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.
2. A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?
- A. The signature on the preoperative consent form is the client’s
- B. The client understands the risks of the surgery
- C. The client is aware of all postoperative care instructions
- D. The client has no further questions about the surgery
Correct answer: A
Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.
3. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:
- A. Administer cardiac compressions
- B. Attach the AED pads to the client
- C. Check for a pulse
- D. Perform rescue breaths
Correct answer: A
Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.
4. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?
- A. Teach deep breathing and coughing to the client.
- B. Assist the client to select food choices from the menu.
- C. Evaluate the client’s response to pain medication.
- D. Monitor the characteristics of the client's chest tube drainage.
Correct answer: B
Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.
5. A patient uses an in-the-canal hearing aid. Which assessment is a priority?
- A. Eyeglass usage
- B. Cerumen buildup
- C. Type of physical exercise
- D. Excessive moisture problems
Correct answer: B
Rationale: When a patient uses an in-the-canal hearing aid, cerumen buildup is a critical issue that needs to be regularly assessed. Cerumen can easily block the sound passage and affect the functionality of the hearing aid. Assessing and managing cerumen buildup is a priority to ensure the proper functioning of the hearing aid. Eyeglass usage, type of physical exercise, and excessive moisture problems are not directly related to the specific issue of cerumen buildup in in-the-canal hearing aids, making them lower priority assessments in this context.
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