HESI LPN
HESI Practice Test for Fundamentals
1. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?
- A. “I kind of like this boy in my class, but he doesn’t like me back.â€
- B. “I want to hang out with the kids in the science club, but the jocks pick on them.â€
- C. “I am so fat, I skip meals to try to lose weight.â€
- D. “My dad wants me to be a lawyer like him, but I just want to dance.â€
Correct answer: C
Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.
2. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?
- A. Administer pain medication 45 minutes prior to dressing change.
- B. Change the dressing quickly to minimize pain.
- C. Provide reassurance to the client that the pain will pass.
- D. Use a less painful dressing technique.
Correct answer: A
Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.
3. When caring for a client prescribed a blood transfusion that parents refuse due to religious beliefs, what should the nurse do?
- A. Examine personal values about the issue.
- B. Proceed with the transfusion if medically necessary.
- C. Refer the issue to the ethics committee.
- D. Administer the blood transfusion without informing the parents.
Correct answer: A
Rationale: When faced with a situation where parents refuse a prescribed treatment due to religious beliefs, the nurse should first examine personal values, understand the client's or family’s beliefs, and respect their rights. Proceeding with the transfusion against the parents' wishes without exploring alternatives or understanding their perspective would violate the principle of respect for autonomy and could damage the therapeutic relationship. Referring the issue to the ethics committee should be considered if a resolution cannot be reached through open communication and negotiation with the family.
4. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:
- A. Positions the irrigating solution bag 30 inches below the stoma
- B. Uses an open system for irrigation
- C. Irrigates the colostomy twice a day
- D. Cleans the stoma with harsh chemicals
Correct answer: A
Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.
5. A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I’m not sure I want to retire.' Which of the following responses should the nurse make?
- A. Let’s talk about how the change in your job status will affect you.
- B. You should consider how retirement will affect your financial situation.
- C. Retirement is a big change, take your time to decide.
- D. Have you thought about what you will do after you retire?
Correct answer: A
Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement. Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job. Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings. Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.
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