HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?
- A. Blood glucose of 350 mg/dL
- B. Serum bicarbonate of 18 mEq/L
- C. Arterial pH of 7.20
- D. Serum potassium of 5.5 mEq/L
Correct answer: C
Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.
2. A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?
- A. The client's family regards the hallucinations from a cultural context
- B. The client will benefit from a talking circle
- C. The client will need a medicine man
- D. The client will need a single room
Correct answer: A
Rationale: Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care. Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.
3. Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older?
- A. A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals
- B. A glycosylated hemoglobin should be obtained at least twice a year
- C. A fasting glucose and a glycosylated hemoglobin should be obtained at 3-month intervals after the initial assessment
- D. A glucose tolerance test, a fasting glucose, and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
Correct answer: A
Rationale: Glycosylated hemoglobin (A1c) testing every 3 months is recommended for clients with poor glycemic control to monitor their average blood sugar levels and adjust treatment as necessary. Choice A is correct as it aligns with the guideline of performing A1c testing every 3 months. Choice B is incorrect because testing at least twice a year may not provide adequate monitoring for clients with poor glycemic control. Choice C is incorrect as it only mentions testing at 3-month intervals without specifying the importance of A1c testing. Choice D is incorrect as it includes unnecessary tests like glucose tolerance test and does not emphasize the importance of more frequent A1c monitoring for clients with poor glycemic control.
4. What should the nurse include in the discharge teaching for a 3-year-old child diagnosed with acute otitis media?
- A. Encourage the child to drink plenty of fluids
- B. Encourage the child to eat a balanced diet
- C. Administer pain medication as needed
- D. Apply warm compresses to the affected ear
Correct answer: A
Rationale: The correct answer is to encourage the child to drink plenty of fluids. This helps to relieve symptoms and prevent dehydration in children with acute otitis media. Encouraging a balanced diet is important for overall health but may not directly impact otitis media symptoms. While administering pain medication as needed can help manage discomfort, it is not a primary discharge teaching for this condition. Applying warm compresses to the affected ear is not typically recommended in acute otitis media cases as it can potentially worsen the infection.
5. A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?
- A. ''I can only report that the client is in satisfactory condition.''
- B. ''Let me give you the telephone number for her room.''
- C. ''I cannot acknowledge if a client is here or not.''
- D. ''I will have the nurse who is working with her call you.''
Correct answer: C
Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.