HESI LPN
HESI Fundamentals Exam Test Bank
1. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?
- A. The client evaluates their behavior after a social interaction.
- B. The client states they are learning to trust others.
- C. The client wishes to find meaningful friendships.
- D. The client expresses concerns about the next generations.
Correct answer: D
Rationale: The correct answer is D because in middle adulthood, individuals often shift their focus towards concerns related to the next generations. They reflect on their roles in guiding and supporting the younger generations. Choice A is incorrect as evaluating behavior after a social interaction is more relevant to self-awareness, which is not a specific developmental task for middle adulthood. Choice B, learning to trust others, is more commonly associated with early adulthood tasks related to forming intimate relationships. Choice C, wishing to find meaningful friendships, is more aligned with tasks associated with young adulthood and social connections.
2. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:
- A. May result in charges of unlawful seclusion and restraint
- B. Leaves the nurse vulnerable to charges of assault and battery
- C. Was appropriate given the client's history of violence
- D. Was necessary to maintain the therapeutic milieu of the unit
Correct answer: A
Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.
3. How can self-injury be prevented when lifting a bedside cabinet?
- A. Standing close to the cabinet when lifting.
- B. Bending at the waist when lifting.
- C. Twisting while lifting to balance the load.
- D. Lifting with a quick motion.
Correct answer: A
Rationale: The correct way to prevent self-injury when lifting a bedside cabinet is by standing close to the cabinet. By standing close, the individual can maintain better control and balance while lifting, reducing the risk of injury. Bending at the waist when lifting (choice B) can strain the back and lead to injury. Twisting while lifting (choice C) can also cause strain and imbalance. Lifting with a quick motion (choice D) can increase the risk of injury due to lack of control and improper body mechanics.
4. 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.
5. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?
- A. Assess the client's respiratory rate and effort.
- B. Measure the client's oxygen saturation level.
- C. Monitor the client's arterial blood gas levels.
- D. Check the client's blood pressure.
Correct answer: B
Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.
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