HESI LPN
HESI Fundamentals Test Bank
1. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?
- A. Report ABG results to the provider
- B. Instruct a client about how to use an incentive spirometer
- C. Administer an enteral feeding to a client who has an established gastrostomy tube
- D. Monitor the color of a client’s urinary output
Correct answer: D
Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.
2. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first?
- A. Evaluate distal capillary refill for delayed perfusion
- B. Check the extremities for bruising and petechiae
- C. Examine the peritibial regions for pitting edema
- D. Palpate the abdomen for tenderness and rigidity
Correct answer: D
Rationale: In a client with a history of cirrhosis and ascites presenting with anorexia and recent hemoptysis, palpating the abdomen for tenderness and rigidity is crucial as it helps in identifying signs of complications related to these conditions. Assessing for abdominal tenderness and rigidity can provide valuable information about the presence of internal bleeding, ascites complications, or liver enlargement. Evaluating distal capillary refill, checking for bruising and petechiae, or examining peritibial regions for pitting edema are important assessments but are not the priority in this case, given the client's history and current symptoms.
3. During a neurological assessment, a healthcare provider is evaluating a client's balance. Which of the following examinations should the provider use for this purpose?
- A. Romberg test
- B. Deep tendon reflexes
- C. Mini-Mental State Examination
- D. Babinski reflex
Correct answer: A
Rationale: The Romberg test is utilized to assess the client's balance and proprioception by having them stand with their eyes closed. This test helps evaluate sensory ataxia, a condition where an individual's balance is affected due to impaired sensory input. Deep tendon reflexes (Choice B) are assessed by tapping a tendon with a reflex hammer to evaluate the integrity of the spinal cord and peripheral nerves; this is not directly related to balance assessment. The Mini-Mental State Examination (Choice C) is a cognitive screening tool used to assess cognitive impairment or dementia, not balance. The Babinski reflex (Choice D) is elicited by stroking the sole of the foot to assess neurologic function, particularly in the corticospinal tract, and is not specific to balance evaluation.
4. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make?
- A. You seem worried. Are you concerned someone may see you without your teeth?
- B. Don't worry, it’s just for the surgery.
- C. You need to follow the instructions.
- D. The dentures need to be removed for a reason.
Correct answer: D
Rationale: The correct response is to provide a clear rationale for the request, as stated in option D. By explaining the purpose behind removing the dentures, the nurse helps the client understand the necessity, which can reduce agitation and promote cooperation. Option A demonstrates empathy by addressing the client's potential concern about being seen without dentures but lacks a direct explanation. Option B dismisses the client's feelings with a casual statement that may not address the underlying issue. Option C is authoritarian and lacks empathy, potentially escalating the client's agitation.
5. The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?
- A. Blood pressure of 150/90 mmHg
- B. Irregular heart rhythm
- C. Shortness of breath
- D. Fatigue
Correct answer: C
Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.