HESI LPN
Fundamentals of Nursing HESI
1. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
- A. Pain related to ischemia
- B. Risk for altered elimination: constipation
- C. Risk for complication: dysrhythmias
- D. Anxiety related to pain
Correct answer: A
Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.
2. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
- A. Hypokalemia
- B. Ketonuria
- C. Peripheral edema
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. In diabetes insipidus, there is excessive urination leading to fluid loss, which can result in electrolyte imbalances such as hypokalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices B, C, and D are incorrect. Ketonuria is typically seen in diabetic ketoacidosis, peripheral edema is more commonly associated with conditions like heart failure or kidney disease, and elevated blood pressure is not a direct complication of diabetes insipidus related to a pituitary gland tumor.
3. The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?
- A. 15 degrees
- B. 30 degrees
- C. 45 degrees
- D. 90 degrees
Correct answer: C
Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.
4. What should parents be taught when a 7-year-old child with a history of seizures is being discharged from the hospital?
- A. Administer antiepileptic medication as prescribed
- B. Ensure the child receives adequate sleep
- C. Restrict the child's activities to prevent seizures
- D. Teach seizure first aid to family members
Correct answer: D
Rationale: Teaching seizure first aid to family members is crucial in ensuring the child's safety during a seizure. This education empowers family members to respond effectively, protect the child from injury, and provide appropriate care. Option A is incorrect because antiepileptic medication should be administered as prescribed, not only when a seizure occurs. Option B, while important for overall health, is not specific to managing seizures. Option C is incorrect as there is no evidence that restricting activities prevents seizures, and it may negatively impact the child's quality of life without offering additional safety benefits.
5. The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?
- A. Obtain emergency help
- B. Feel for a carotid pulse
- C. Bring a glucometer to the room
- D. Check the blood pressure
Correct answer: A
Rationale: The correct answer is to instruct the UAP to obtain emergency help first. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.