HESI LPN
HESI Fundamentals 2023 Test Bank
1. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?
- A. Assess the client's mobility
- B. Evaluate the pedal pulses
- C. Monitor skin temperature
- D. Check for swelling
Correct answer: B
Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.
2. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct answer: B
Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.
3. The school nurse is presenting a class to a group of students about common overuse disorders. Which disorder would the school nurse include?
- A. Dislocated radial head
- B. Transient synovitis of the hip
- C. Osgood-Schlatter disease
- D. Scoliosis
Correct answer: C
Rationale: Osgood-Schlatter disease is a common overuse injury that specifically affects the knee. It is characterized by inflammation of the patellar ligament at the tibial tuberosity due to repetitive strain on the growth plate during activities such as running and jumping. Dislocated radial head (Choice A) is not an overuse disorder but rather an injury usually seen in young children. Transient synovitis of the hip (Choice B) is an acute hip condition and not typically classified as an overuse disorder. Scoliosis (Choice D) is a condition characterized by an abnormal lateral curvature of the spine and is not considered an overuse disorder.
4. A 3-year-old child is being discharged after being treated for dehydration. What should be included in the discharge teaching?
- A. Monitor for signs of infection
- B. Monitor for signs of dehydration
- C. Monitor for signs of hypovolemia
- D. Monitor for signs of malnutrition
Correct answer: B
Rationale: The correct answer is to monitor for signs of dehydration. After treatment for dehydration, it is crucial to educate caregivers about recognizing early signs of dehydration to prevent its recurrence. Monitoring for dehydration ensures that appropriate measures can be taken promptly if signs reappear. Choices A, C, and D are incorrect because infection, hypovolemia, and malnutrition, while important considerations in healthcare, are not the primary focus after treating dehydration in a 3-year-old child.
5. In formulating an objective of a community care plan, she expected results and people taking part in the activities should be clearly defined. This refers to an objective which is:
- A. time-bound
- B. specific
- C. resource-oriented
- D. measurable
Correct answer: B
Rationale: The correct answer is 'specific.' In formulating a community care plan, defining expected results and participant roles require objectives to be specific to provide clear guidance and outcomes. 'Time-bound' refers to setting deadlines, 'resource-oriented' focuses on utilizing available resources efficiently, and 'measurable' indicates the ability to quantify progress, but these aspects do not necessarily address the need for clarity and definition in defining expected results and participant roles.