HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?
- A. Troponin level of 0.5 ng/mL
- B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
- C. Serum potassium of 4.5 mEq/L
- D. Blood glucose of 180 mg/dL
Correct answer: A
Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.
2. What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?
- A. Active and passive range of motion exercises twice a day
- B. Every 4 hours incentive spirometer
- C. Chest physiotherapy twice a day
- D. Repositioning every 2 hours around the clock
Correct answer: C
Rationale: Chest physiotherapy is essential for clients with amyotrophic lateral sclerosis (ALS) to prevent atelectasis and pneumonia. Chest physiotherapy aids in clearing secretions, maintaining lung function, and preventing respiratory complications. Active and passive range of motion exercises (Choice A) are important for maintaining joint mobility but are not directly associated with preventing atelectasis and pneumonia in ALS. Incentive spirometer use every 4 hours (Choice B) is beneficial for lung expansion and preventing atelectasis but may not be as effective as chest physiotherapy in managing secretions. Repositioning every 2 hours (Choice D) is crucial for preventing pressure ulcers but is not directly related to preventing atelectasis and pneumonia in ALS.
3. The nurse is assessing the 'resilience' of a 16-year-old boy. Which exemplifies an external protective factor that may help to promote resiliency in this child?
- A. His ability to take control of his own decisions
- B. His ability to accept his own limitations
- C. His caring relationship with members of his family
- D. His knowledge of when to continue or stop with goal achievement
Correct answer: C
Rationale: A caring relationship with family members is an external protective factor that promotes resilience. It provides emotional support, stability, and a sense of belonging, which are crucial elements in building resilience. Choices A, B, and D are more related to internal factors and individual traits rather than external factors like family relationships, which play a significant role in promoting resilience. Taking control of decisions, accepting limitations, and knowing when to stop or continue with goals are internal factors that contribute to personal resilience but do not directly represent external protective factors like family relationships.
4. A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?
- A. Administering a bronchodilator
- B. Administering an antihistamine
- C. Administering a corticosteroid
- D. Administering oxygen
Correct answer: A
Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways, making breathing easier and relieving acute symptoms of asthma. Antihistamines are not the first-line treatment for asthma exacerbations; they are more commonly used for allergic reactions. Corticosteroids are beneficial in reducing inflammation in asthma but are usually administered after bronchodilators to provide long-term control. Oxygen therapy may be necessary in severe cases of asthma exacerbation, but bronchodilators take precedence in improving airway patency and respiratory distress.
5. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?
- A. Thrombocytopenia
- B. Polycythemia
- C. Decreased ESR
- D. Positive ASO titer
Correct answer: D
Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.