HESI LPN
Practice HESI Fundamentals Exam
1. During auscultation of a client experiencing chest pain worsened by inspiration, a nurse hears a high-pitched scratching sound in both systole and diastole with the diaphragm of the stethoscope placed at the left sternal border. Which of the following heart sounds should the nurse document?
- A. Pericardial friction rub
- B. Murmur
- C. S1 and S2
- D. Bruit
Correct answer: A
Rationale: The correct answer is 'Pericardial friction rub.' A pericardial friction rub is a high-pitched, scratching sound heard in both systole and diastole, which is characteristic of pericardial inflammation. This sound is different from a murmur, which is a swooshing or blowing sound due to turbulent blood flow. S1 and S2 are normal heart sounds, and a bruit is a whooshing sound caused by turbulent blood flow in an artery, not related to pericardial inflammation.
2. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?
- A. Position the client 6.1 m (20 ft) away from the Snellen chart
- B. Instruct the client to follow a finger through the six cardinal positions of gaze
- C. Ask the client to cover their right eye during assessment of the left eye
- D. Hold a finger 46 cm (18 inches) away from the client's eye
Correct answer: B
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.
3. During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?
- A. Ensure the bladder of the BP cuff surrounds 80% of their arm.
- B. Use the BP cuff on the forearm if the upper arm is not accessible.
- C. Apply the BP cuff loosely around the arm.
- D. Use a pediatric cuff for adults with small arms.
Correct answer: A
Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.
4. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?
- A. The client moves the walker ahead 25.4 cm with each step
- B. The client picks up the walker with each step
- C. The client stands with elbows slightly bent while holding the walker
- D. The client stoops slightly forward when moving the walker
Correct answer: C
Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.
5. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?
- A. Using waxed floss helps prevent bleeding
- B. Flossing removes plaque and tartar from the teeth
- C. Flossing at least 3 times a day is beneficial
- D. Applying toothpaste before flossing is harmful
Correct answer: B
Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.
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