HESI LPN
HESI Fundamentals Exam
1. A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?
- A. Examine the mouth first
- B. Reassure the child
- C. Examine the mouth last
- D. Offer a pacifier
Correct answer: C
Rationale: In this scenario, it is crucial to prioritize the comfort of the child. By examining the mouth last, discomfort is minimized, and the child is given the opportunity to settle down. Choosing to examine the mouth first may escalate the distress of the child further. While reassuring the child is important, in this case, addressing the physical discomfort before providing emotional reassurance is more effective. Offering a pacifier may provide some comfort, but addressing the immediate physical discomfort by examining the mouth last is the most appropriate action to help the child settle down after the procedure.
2. In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?
- A. Orient the client to time, person, and place
- B. Tell the client that the behavior is inappropriate
- C. Escort the manic client to her room, with assistance
- D. Tell the client that smoking privileges are revoked for 24 hours
Correct answer: C
Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.
3. What is an important dietary consideration for a child with renal failure?
- A. Low-protein, low-sodium diet
- B. High-protein, high-sodium diet
- C. Increased calcium intake
- D. High-fiber diet
Correct answer: A
Rationale: A low-protein, low-sodium diet is crucial for a child with renal failure because it helps reduce the workload on the kidneys and minimize complications. High-protein and high-sodium diets can place excessive strain on the kidneys and worsen the condition. Increased calcium intake is not typically a primary consideration for renal failure in children. While a high-fiber diet can be beneficial for overall health, it is not a specific priority for managing renal failure in children.
4. A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding 'stronger pain medications.' What initial action is most important for the LPN/LVN to take?
- A. Ask about any past history of drug abuse or addiction.
- B. Measure the pulse volume and capillary refill distal to the infiltration.
- C. Compress the infiltrated tissue to measure the degree of edema.
- D. Evaluate the extent of ecchymosis over the forearm area.
Correct answer: B
Rationale: The most important initial action for the LPN/LVN to take in this situation is to measure the pulse volume and capillary refill distal to the infiltration. This assessment helps evaluate the severity of the infiltration and the circulation in the affected arm. Asking about past history of drug abuse or addiction (Choice A) is not the priority when addressing acute arm pain and infiltration. Compressing the infiltrated tissue (Choice C) may exacerbate the pain and is not recommended as the first step. Evaluating the extent of ecchymosis (Choice D) is not as critical as assessing the circulation in the affected arm, which is better addressed by measuring pulse volume and capillary refill.
5. After witnessing a preoperative client sign the surgical consent form, what are the legal implications of the nurse's signature on the client's form as a witness?
- A. The client voluntarily grants permission for the procedure to be done
- B. The surgeon has explained to the client why the surgery is necessary
- C. The client is competent to sign the consent without impairment of judgment
- D. The client understands the risks and benefits associated with the procedure
Correct answer: C
Rationale: The nurse's signature on the consent form signifies that the client is competent to sign the consent without impairment of judgment. This legal implication ensures that the client possesses the necessary capacity to make decisions about their healthcare. Choice A is incorrect because the nurse's signature does not imply the client's voluntary permission for the procedure. Choice B is incorrect as it pertains to the surgeon's responsibility, not the nurse's. Choice D is incorrect as the nurse's signature does not confirm the client's understanding of the risks and benefits associated with the procedure.