HESI LPN
Community Health HESI Exam
1. A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?
- A. Lethargy
- B. Agitation
- C. Ataxia
- D. Hearing loss
Correct answer: A
Rationale: Lethargy is a critical finding that requires the nurse's immediate attention when a client with a recent skull fracture is readmitted to the hospital. It can indicate increased intracranial pressure or other serious complications such as hemorrhage or infection. Addressing lethargy promptly is crucial to prevent further deterioration. Agitation, ataxia, and hearing loss are important to assess but do not signify the same level of urgency as lethargy in this context.
2. The appropriate order of steps in active management of the third stage of labor includes:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
- C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
- D. Controlled cord traction, fundal massage, and oxytocin.
Correct answer: C
Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.
3. A nurse is assessing a 10-month-old infant. What developmental milestone should the nurse expect to observe?
- A. Crawling
- B. Sitting without support
- C. Standing with assistance
- D. Pulling to a stand
Correct answer: D
Rationale: The correct answer is D: Pulling to a stand. By 10 months of age, most infants should be able to pull themselves up to a standing position while holding onto furniture or other support. This milestone indicates good strength and coordination in the lower body. Choice A, Crawling, is typically achieved around 6-9 months of age. Choice B, Sitting without support, usually occurs around 6-8 months. Choice C, Standing with assistance, can typically be seen around 9-12 months, but pulling to a stand is a more advanced milestone expected by 10 months.
4. A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?
- A. Administer a PRN dose of an anticholinergic medication.
- B. Document the findings and continue to monitor the client.
- C. Assess the client's blood glucose level.
- D. Notify the healthcare provider immediately.
Correct answer: A
Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.
5. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?
- A. Advise the client that suctioning will be used to obtain another specimen
- B. Re-instruct the client in coughing techniques to obtain another specimen
- C. Provide the client a glass of water and mouthwash to rinse the mouth
- D. Label the container and place the container in a biohazard transport bag
Correct answer: C
Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.