HESI LPN
HESI Fundamentals Exam Test Bank
1. When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?
- A. A halo of erythema on the surrounding skin
- B. Presence of serous drainage
- C. Edema around the wound
- D. Absence of granulation tissue
Correct answer: A
Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.
2. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The professional should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 107 mL/hr
- B. 120 mL/hr
- C. 95 mL/hr
- D. 100 mL/hr
Correct answer: A
Rationale: To calculate the infusion rate, divide the total volume (750 mL) by the total time (7 hr). 750 ÷ 7 ≈ 107 mL/hr. Choice A is correct because it accurately calculates the infusion rate based on the total volume and time. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate in this scenario.
3. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?
- A. Administer oxygen via a nasal cannula.
- B. Measure the client's vital signs.
- C. Obtain a 12-lead ECG.
- D. Encourage the client to use pursed-lip breathing.
Correct answer: A
Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.
4. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?
- A. Where the client ate his breakfast
- B. The times for routine vital sign measurements
- C. The exact times the client had visitors
- D. The type of transmission-based precautions in place
Correct answer: D
Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.
5. Which client statement from the assessment data is likely to explain their noncompliance with propranolol hydrochloride (Inderal)?
- A. I have problems with diarrhea.
- B. I have difficulty falling asleep.
- C. I have diminished sexual function.
- D. I often feel jittery.
Correct answer: C
Rationale: The correct answer is C. Propranolol hydrochloride (Inderal) is known to cause side effects such as diminished sexual function, which can lead to noncompliance with the medication due to its impact on quality of life. Choices A, B, and D are less likely to be associated with propranolol hydrochloride. While diarrhea, difficulty falling asleep, and feeling jittery are possible side effects of propranolol, they are not as commonly reported as diminished sexual function. Therefore, choice C is the most likely reason for the client's noncompliance.
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