HESI LPN
Practice HESI Fundamentals Exam
1. The healthcare provider is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The healthcare provider needs to
- A. Assess for abdominal distention
- B. Maintain the infant in an upright position
- C. Begin feeding formula when the infant is alert
- D. Pump the shunt to assess for proper function
Correct answer: A
Rationale: Assessing for abdominal distention is crucial in this situation as it can indicate a complication with the shunt or fluid accumulation. Abdominal distention may suggest an issue with the shunt placement, such as obstruction or overdrainage, which requires immediate intervention. Maintaining the infant in an upright position (Choice B) is not the priority immediately postoperatively following a ventriculoperitoneal shunt placement. Beginning formula feedings when the infant is alert (Choice C) may be appropriate but is not the priority over assessing for abdominal distention. Pumping the shunt to assess for proper function (Choice D) is not a recommended nursing intervention postoperatively and should be done by a qualified healthcare provider.
2. A client has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
- A. Ensure the catheter tubing is free of kinks.
- B. Clean the perineal area with antiseptic solution daily.
- C. Irrigate the catheter with normal saline every shift.
- D. Secure the catheter to the client's leg.
Correct answer: B
Rationale: Cleaning the perineal area with antiseptic solution daily is essential to prevent infection when caring for a client with an indwelling urinary catheter. This practice helps reduce the risk of introducing pathogens into the urinary tract. Ensuring the catheter tubing is free of kinks (Choice A) is important for maintaining proper urine flow but is not directly related to preventing infection. Irrigating the catheter with normal saline every shift (Choice C) is not a routine practice and can increase the risk of introducing pathogens. Securing the catheter to the client's leg (Choice D) is important for stability but does not directly prevent infection.
3. A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should roll the NPH vial between my hands before drawing it up.
- B. I should draw up the NPH insulin before the regular insulin.
- C. I should inject air into the vial of regular insulin first.
- D. I should wait 10 minutes after mixing the insulin to inject it.
Correct answer: A
Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.
4. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?
- A. An x-ray shows the end of the tube above the pylorus.
- B. The tube is aspirated and contains clear gastric fluid.
- C. The tube is flushed with sterile water without resistance.
- D. The client does not cough or choke during tube insertion.
Correct answer: B
Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.
5. A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?
- A. 8 oz of ice chips
- B. 8 oz of ice chips
- C. 1 cup of broth
- D. 1 cup of broth
Correct answer: A
Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.
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