HESI LPN
HESI Fundamentals Exam
1. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?
- A. Measure the client's urine output.
- B. Auscultate the client's lung sounds.
- C. Assess the client's apical pulse.
- D. Check the client's blood pressure.
Correct answer: B
Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.
2. While a client is receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?
- A. Monitor the client's blood glucose level every 4 hours.
- B. Change the TPN tubing every 72 hours.
- C. Weigh the client daily.
- D. Change the TPN bag every 24 hours.
Correct answer: D
Rationale: The correct action is to change the TPN bag every 24 hours to reduce the risk of infection. Changing the TPN tubing every 72 hours (Choice B) may increase the risk of contamination. Monitoring the client's blood glucose level every 4 hours (Choice A) is important but not specific to TPN administration. Weighing the client daily (Choice C) is essential for monitoring fluid status but is not directly related to TPN administration.
3. A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?
- A. Call for emergency transport to the hospital
- B. Immobilize the limb and joints above and below the injury
- C. Assess the child and the extent of the injury
- D. Apply cold compresses to the injured area
Correct answer: C
Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.
4. The healthcare professional is developing a care plan for a client with depression. What should be included in the plan?
- A. Regular physical activity
- B. Scheduled sleep patterns
- C. Social interaction with family and friends
- D. All of the above
Correct answer: D
Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.
5. What should be included in the medical management of a sickle cell crisis?
- A. Information for parents on home care
- B. Adequate hydration and pain management
- C. Pain management and iron supplements
- D. Adequate oxygenation and factor VIII
Correct answer: B
Rationale: The correct answer is B: Adequate hydration and pain management. During a sickle cell crisis, it is essential to provide hydration to prevent vaso-occlusive events and manage pain effectively with analgesics. Adequate hydration helps maintain blood flow and prevent further sickling of red blood cells. Pain management is crucial to alleviate the severe pain associated with sickle cell crises. Options A, C, and D are incorrect. Providing information for parents on home care (Option A) may be important for ongoing management but is not specific to an acute crisis. Iron supplements (Option C) are not typically indicated during a sickle cell crisis. Adequate oxygenation and factor VIII (Option D) are not primary interventions for managing a sickle cell crisis; instead, oxygen therapy may be considered in severe cases, and factor VIII is not a standard treatment for sickle cell disease.