HESI LPN
HESI Fundamentals Exam Test Bank
1. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN?
- A. Creating a plan of care for a client who is recovering following a stroke.
- B. Assessing a pressure injury on a client who is on bed rest.
- C. Providing nasopharyngeal suctioning for a client who has pneumonia.
- D. Teaching a client who has asthma to use a metered-dose inhaler.
Correct answer: C
Rationale: The correct answer is providing nasopharyngeal suctioning for a client who has pneumonia. This task falls within the practical nurse's scope of practice, as it involves direct patient care and basic interventions. Creating a plan of care for a client recovering from a stroke involves critical thinking and comprehensive assessment, which are typically responsibilities of registered nurses. Assessing a pressure injury requires specialized wound care knowledge, often performed by wound care specialists or registered nurses with wound care training. Teaching a client to use a metered-dose inhaler involves patient education and requires a thorough understanding of asthma management, making it more suitable for a registered nurse.
2. The nurse is performing a physical assessment on a client with insulin-dependent diabetes mellitus. Which client complaint calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced sensation in the lower leg
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct answer: A
Rationale: Diaphoresis and shakiness are classic signs of hypoglycemia in a client with insulin-dependent diabetes mellitus. Hypoglycemia is a medical emergency that requires immediate intervention to prevent further complications. The nurse should address this complaint promptly by providing a fast-acting source of glucose to raise the client's blood sugar levels. Reduced sensation in the lower leg may indicate peripheral neuropathy, which is a common complication of diabetes but does not require immediate action unless there are signs of injury. Intense thirst and hunger are symptoms of hyperglycemia, which also requires intervention but not as urgently as hypoglycemia. A painful hematoma on the thigh may require assessment and management, but it is not as urgent as addressing hypoglycemia.
3. The nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox). Which site is most appropriate for the LPN/LVN to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Abdomen
- D. Dorsogluteal site
Correct answer: C
Rationale: The abdomen is the most appropriate site for administering subcutaneous injections of enoxaparin (Lovenox). Enoxaparin is typically administered in the abdomen due to better absorption and reduced risk of injury to underlying structures. The deltoid muscle is not recommended for subcutaneous injections of enoxaparin due to the potential risk of injury to underlying structures. The ventrogluteal and dorsogluteal sites are more appropriate for intramuscular injections rather than subcutaneous injections.
4. The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?
- A. Hoarseness of the voice.
- B. Slight swelling at the incision site.
- C. Tingling around the mouth.
- D. Mild fever.
Correct answer: C
Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.
5. Rh incompatibility occurs when an Rh-negative woman is carrying an Rh-positive fetus.
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Never
Correct answer: B
Rationale: Rh incompatibility occurs when an Rh-negative woman is carrying an Rh-positive fetus, not the other way around. Therefore, the statement that an Rh-positive woman is carrying an Rh-negative fetus is incorrect. Rh incompatibility can lead to hemolytic disease of the newborn, where maternal antibodies attack the fetal red blood cells. Choice A is incorrect because the statement is false. Choice C is incorrect as Rh incompatibility has a clear cause and effect relationship. Choice D is incorrect as Rh incompatibility can occur, but it depends on the Rh status of the mother and fetus.