HESI LPN
HESI Fundamentals Test Bank
1. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?
- A. That indicates you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are dilating and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct answer: D
Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.
2. A client with brain cancer is transferring to hospice care. The client's son tells the nurse, 'I don’t know what to tell my dad if he asks how he is going to die.' Which of the following is an appropriate response by the nurse?
- A. “Let’s talk more about your dad’s condition.”
- B. “The social worker will help you answer those questions.”
- C. “I think that you should discuss this with the hospice nurse.”
- D. “Try to help your dad enjoy this time as much as he can.”
Correct answer: D
Rationale: Choosing option D, 'Try to help your dad enjoy this time as much as he can,' is the most appropriate response by the nurse. This response shows empathy and compassion towards the client and their family during this difficult transition. The focus on supporting the client in enjoying their remaining time reflects a holistic approach to care. Options A, B, and C are not the best responses in this situation. Option A could lead to unnecessary details that might be overwhelming for the family. Option B shifts the responsibility to the social worker without providing immediate support. Option C deflects the son's concerns to another healthcare professional when emotional support is needed.
3. The healthcare provider is reviewing the plan of care for a client with a newly placed colostomy. Which outcome would indicate effective client teaching?
- A. Client demonstrates how to irrigate the colostomy.
- B. Client verbalizes understanding of dietary changes.
- C. Client performs ostomy care independently.
- D. Client expresses feelings about the impact of the colostomy.
Correct answer: C
Rationale: The correct answer is C because effective teaching is demonstrated when the client can independently perform ostomy care. This indicates that the client has understood and retained the information provided during teaching. Choices A, B, and D are incorrect because demonstrating how to irrigate the colostomy, verbalizing understanding of dietary changes, and expressing feelings about the impact of the colostomy are important aspects of care but do not directly reflect the client's ability to apply the taught information in a practical setting.
4. The patient is receiving chemotherapy for breast cancer. Which of the following laboratory values would be most important to monitor?
- A. White blood cell count
- B. Hemoglobin level
- C. Serum creatinine
- D. Blood glucose level
Correct answer: A
Rationale: Monitoring the white blood cell count is crucial when a patient is undergoing chemotherapy for breast cancer. Chemotherapy can lead to neutropenia, a condition of low white blood cell count, which significantly increases the risk of infections. Monitoring white blood cell count helps healthcare providers intervene promptly to prevent severe infections. Hemoglobin level, while important in assessing oxygen-carrying capacity, is not the priority in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer.
5. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
- A. Check the IV tubing for obstruction
- B. Increase the infusion rate
- C. Administer a bolus of fluid
- D. Replace the IV catheter
Correct answer: A
Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.
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