HESI LPN
Practice HESI Fundamentals Exam
1. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?
- A. I will only have to wear this for 6 months.
- B. I should inspect my skin daily.
- C. The brace will be worn day and night.
- D. I can take it off when I shower.
Correct answer: A
Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.
2. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?
- A. Apply the stockings with the creases on the front of the leg.
- B. Apply the stockings while the client's legs are in a dependent position.
- C. Remove the stockings at least once per shift.
- D. Remove the stockings while the client is sitting in a reclining chair.
Correct answer: C
Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.
3. A client with schizophrenia is receiving haloperidol (Haldol). The nurse should monitor the client for which of the following side effects?
- A. Tachycardia
- B. Hypotension
- C. Extrapyramidal symptoms
- D. Hyperglycemia
Correct answer: C
Rationale: The correct answer is C: Extrapyramidal symptoms. Haloperidol is a first-generation antipsychotic that can lead to extrapyramidal symptoms such as tardive dyskinesia and akathisia. These side effects are common with the use of typical antipsychotics. Choice A, Tachycardia, is not a common side effect of haloperidol. Choice B, Hypotension, is also not a typical side effect associated with haloperidol use. Choice D, Hyperglycemia, is not directly linked to haloperidol administration, as it is more commonly associated with other medications like atypical antipsychotics or certain medical conditions.
4. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct answer: C
Rationale: A sodium level of 110 mEq/L is critically low and can indicate severe dehydration and electrolyte imbalance, requiring immediate intervention.
5. Which manifestation should the nurse expect to assess in a patient with fluid volume deficit?
- A. Headache and muscle cramps
- B. Dyspnea and respiratory crackles
- C. Increased pulse rate and blood pressure
- D. Orthostatic hypotension and flat neck veins
Correct answer: D
Rationale: Orthostatic hypotension and flat neck veins are classic manifestations of fluid volume deficit. When the body loses fluid, blood volume decreases, leading to decreased venous return to the heart, resulting in orthostatic hypotension and flat neck veins. Choices A, B, and C are more indicative of other conditions such as dehydration, respiratory issues, or compensatory mechanisms in response to hypovolemia, respectively.