HESI LPN
Fundamentals HESI
1. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?
- A. ''I am going to listen to your abdomen.''
- B. ''You need to wait until the surgeon evaluates your condition.''
- C. ''You can have clear liquids, but let me check with the surgeon first.''
- D. ''It is best to start with small sips of clear liquids and observe how you feel.''
Correct answer: A
Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client’s gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.
2. What is a common complication of untreated type 1 diabetes in children?
- A. Diabetic ketoacidosis
- B. High blood pressure
- C. Asthma
- D. Frequent infections
Correct answer: A
Rationale: Diabetic ketoacidosis is a serious complication of untreated type 1 diabetes in children. It is characterized by high blood sugar levels, ketones in the urine, and acidosis. Prompt medical attention is required to manage this condition. High blood pressure (Choice B) can be a complication of diabetes but is not as directly linked to untreated type 1 diabetes as diabetic ketoacidosis. Asthma (Choice C) and frequent infections (Choice D) are not typically associated with untreated type 1 diabetes in children.
3. A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
- A. Patch one eye.
- B. Reorient often.
- C. Range of motion.
- D. Evaluate swallow
Correct answer: B
Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.
4. The client with acute hypocalcemia is admitted to the unit. Nursing action should include:
- A. Implement seizure precautions
- B. Assess for hypoglycemia
- C. Monitor for visual changes
- D. Observe for muscle weakness
Correct answer: A
Rationale: The correct action for a client with acute hypocalcemia is to implement seizure precautions. Hypocalcemia can lead to tetany and seizures due to neuromuscular irritability. Assessing for hypoglycemia (choice B) is not directly related to hypocalcemia. Monitoring for visual changes (choice C) is more indicative of conditions like hyperglycemia or retinal disorders. Observing for muscle weakness (choice D) is a common symptom of hypocalcemia but does not address the immediate risk of seizures, which is why implementing seizure precautions is the priority nursing action.
5. As a community organizer, the PHN facilitates the planning and implementation of program subjects in the community. In the light of the PHC approach, these programs/projects should be characterized by the following except:
- A. managed by the community leaders/members
- B. managed by non-government organizations for the people to ensure success
- C. compatible with available resources
- D. developmental in nature
Correct answer: B
Rationale: In the context of the PHC approach, programs should be characterized by being managed by community leaders/members (Choice A). This ensures community involvement and ownership. Programs should also be compatible with available resources (Choice C) to be sustainable and effective. Additionally, programs should be developmental in nature (Choice D), focusing on long-term improvements. Choice B is incorrect because programs should not be solely managed by non-government organizations; instead, they should be driven by the community to promote sustainability and empowerment.