HESI LPN
Community Health HESI Practice Exam
1. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
- A. Elevate leg on 2 pillows
- B. Apply support stockings
- C. Apply warm compresses
- D. Maintain complete bed rest
Correct answer: A
Rationale: The highest priority nursing intervention for a client with thrombophlebitis of the left leg is to elevate the leg on 2 pillows. Elevating the leg helps reduce swelling and pain associated with thrombophlebitis by promoting venous return. Applying support stockings (choice B) can be beneficial but is not the highest priority as elevation is more effective in the acute phase. Applying warm compresses (choice C) may worsen the condition by dilating the blood vessels, leading to increased pain and swelling. Maintaining complete bed rest (choice D) is important, but elevation takes precedence to improve circulation and reduce the risk of complications.
2. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?
- A. Position the client 6.1 m (20 ft) away from the Snellen chart
- B. Instruct the client to follow a finger through the six cardinal positions of gaze
- C. Ask the client to cover their right eye during assessment of the left eye
- D. Hold a finger 46 cm (18 inches) away from the client's eye
Correct answer: B
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.
3. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?
- A. It may take 3 to 4 weeks to achieve therapeutic effects.
- B. Keep your dietary salt intake consistent.
- C. Avoid eating aged cheese and chicken liver.
- D. Eat foods high in fiber such as whole grain breads.
Correct answer: B
Rationale: The correct answer is B: 'Keep your dietary salt intake consistent.' Consistent salt intake is crucial when taking lithium carbonate to avoid lithium toxicity or ineffectiveness due to its renal excretion mechanism. Option A is incorrect because it focuses on the time to achieve therapeutic effects, which is important but not as critical as maintaining consistent salt intake. Option C is incorrect as it mentions avoiding aged cheese and chicken liver, which is more relevant for individuals taking MAOIs. Option D is incorrect as it suggests eating high-fiber foods, which is not directly related to lithium carbonate therapy.
4. Round off these numbers to the nearest tenth:
- A. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- B. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- C. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- D. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
Correct answer: B
Rationale: The correct answer is B. When rounding off to the nearest tenth, 1.027 becomes 1.0 because the digit in the hundredth's place is less than 5. For the other numbers, they are rounded correctly to the nearest tenth: 5.5778 = 5.6, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7. Therefore, option B is the most accurate in rounding off these numbers to the nearest tenth. Choices A, C, and D are incorrect as they do not round 1.027 to 1.0 as required when rounding to the nearest tenth.
5. A client with chronic kidney disease is prescribed lanthanum carbonate. The nurse should monitor for which potential side effect?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct answer: A
Rationale: Lanthanum carbonate is prescribed in chronic kidney disease to bind dietary phosphorus in the gastrointestinal tract. This action can lead to decreased phosphorus absorption and potential hypercalcemia due to the increased serum calcium levels. Therefore, the nurse should monitor the client for signs and symptoms of hypercalcemia, such as confusion, fatigue, and muscle weakness. Choices B, C, and D are incorrect as lanthanum carbonate's mechanism of action does not lead to hypocalcemia, hyperkalemia, or hypokalemia.