HESI LPN
Fundamentals HESI
1. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding would be most concerning?
- A. Peripheral edema
- B. Crackles in the lungs
- C. Jugular vein distention
- D. Hepatomegaly
Correct answer: B
Rationale: The correct answer is B: Crackles in the lungs. Crackles in the lungs indicate pulmonary congestion, a serious complication of left-sided heart failure. The presence of crackles suggests fluid accumulation in the lungs, impairing gas exchange and potentially leading to respiratory distress. Immediate intervention is necessary to prevent worsening respiratory function. Choices A, C, and D are incorrect: Peripheral edema is a common finding in heart failure but may not be as acutely concerning as pulmonary congestion. Jugular vein distention is associated with right-sided heart failure, not left-sided heart failure. Hepatomegaly is often seen in liver conditions and right-sided heart failure, not specifically left-sided heart failure.
2. When describing urticaria, what would an instructor include?
- A. It is a type IV hypersensitivity reaction.
- B. Histamine release leads to vasodilation.
- C. Wheals appear first followed by erythema.
- D. The nonpruritic rash blanches with pressure.
Correct answer: B
Rationale: The correct answer is B. Urticaria is a type I hypersensitivity reaction where histamine release leads to vasodilation and the formation of characteristic wheals. Choice A is incorrect as urticaria is associated with type I hypersensitivity, not type IV. Choice C is incorrect because in urticaria, erythema typically appears before the development of wheals. Choice D is incorrect as urticaria is typically pruritic and does not blanch with pressure.
3. During a large community disaster, a man states that the blast threw him out of a second-story window. Which action should the nurse implement first?
- A. Logroll the client to his side and assess for back injuries
- B. Perform a complete neurological assessment
- C. Open the client's airway immediately
- D. Place the nurse's hands around the client's neck to stabilize
Correct answer: D
Rationale: In this situation, the nurse should first stabilize the client's neck to prevent potential spinal cord injuries. Logrolling the client or performing other assessments should only be done after ensuring spinal stabilization. Opening the airway immediately is important in cases of airway obstruction, but stabilizing the neck takes priority in this scenario. Performing a complete neurological assessment may delay immediate stabilization, which is crucial in suspected spinal injuries.
4. What is a primary concern for a child with a new diagnosis of diabetes mellitus?
- A. Increased growth rate
- B. Risk of hyperglycemia
- C. Risk of dehydration
- D. Improved appetite
Correct answer: B
Rationale: The correct answer is B: Risk of hyperglycemia. When a child is newly diagnosed with diabetes mellitus, one of the primary concerns is the risk of hyperglycemia, which refers to high blood glucose levels. Hyperglycemia can lead to various complications if not managed properly, making it crucial to stabilize blood glucose levels. Choices A, C, and D are incorrect because increased growth rate, risk of dehydration, and improved appetite are not primary concerns specifically associated with a new diagnosis of diabetes mellitus.
5. A healthcare professional is preparing to insert an NG tube for a client admitted with bowel obstruction. Which of the following should the healthcare professional do first?
- A. Explain the procedure to the client
- B. Measure the length of the NG tube
- C. Lubricate the NG tube
- D. Place the client in a high Fowler’s position
Correct answer: A
Rationale: Explaining the procedure to the client is the initial and most important step that the healthcare professional should take before inserting an NG tube. By explaining the procedure, the healthcare professional ensures the client's understanding, obtains informed consent, and fosters cooperation. Measuring the length of the NG tube, lubricating the tube, and positioning the client in a high Fowler's position are essential steps in the NG tube insertion process but should come after the client has been informed and consented to the procedure.