HESI LPN
Practice HESI Fundamentals Exam
1. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain radiate to other areas?
- C. Does the pain increase with movement?
- D. Can you rate your pain on a scale of 1 to 10?
Correct answer: A
Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.
2. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Encourage the client to increase fluid intake.
- B. Monitor the client's blood glucose level.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct answer: B
Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.
3. The charge nurse on the unit observes that one of the staff nurses is not using proper hand washing techniques. Which is the most appropriate initial approach to correct the behavior?
- A. Remind the nurse that proper hand washing prevents infection
- B. Discuss what the nurse knows about proper hand hygiene
- C. Provide a review of the hand washing policy
- D. Refer the nurse to the infection control nurse
Correct answer: B
Rationale: The most appropriate initial approach to correct the behavior of improper hand washing by a staff nurse is to discuss what the nurse knows about proper hand hygiene. This approach helps in identifying any knowledge gaps the nurse may have and provides an opportunity to educate and correct the behavior. Option A is not the best choice as simply reminding the nurse about the importance of hand washing may not address the underlying issue of knowledge or technique. Option C, providing a review of the hand washing policy, may be necessary but is not the most immediate step to take. Option D, referring the nurse to the infection control nurse, is premature and may not be necessary if the issue can be resolved through education and communication first.
4. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?
- A. Wearing gloves during the procedure
- B. Using a sterile solution
- C. Irrigating from the inner to the outer canthus
- D. Positioning the client's head properly
Correct answer: A
Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.
5. A client has an order for 1000 ml of D5W over an 8-hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
- A. Ask the client if there are any breathing problems
- B. Have the client void as much as possible
- C. Check the vital signs
- D. Auscultate the lungs
Correct answer: D
Rationale: The correct answer is D: Auscultate the lungs. When a significant amount of fluid has been infused, especially in a short period, it is crucial to assess for signs of fluid overload or pulmonary complications, such as crackles or decreased breath sounds. This can be achieved by auscultating the lungs. Choice A, asking the client about breathing problems, may provide valuable information, but direct assessment through auscultation takes priority. Choice B, having the client void, and Choice C, checking vital signs, are important nursing actions but are not as urgent as assessing the lungs for potential complications in this scenario.
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