HESI LPN
Community Health HESI Practice Exam
1. A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
- A. Weight gain of 2 pounds or more in a 48-hour period
- B. Urinating 4 to 5 times a day
- C. A significant decrease in appetite
- D. Appearance of non-pitting ankle edema
Correct answer: A
Rationale: A rapid weight gain of 2 pounds or more in a 48-hour period may indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and intervention. This finding is crucial in managing chronic congestive heart failure as it signifies a potential exacerbation of the condition. Choices B, C, and D are less concerning in this context. Urinating 4 to 5 times a day is within the normal range for most individuals and may not be directly related to heart failure. A significant decrease in appetite may be due to various factors and might not be an immediate cause for concern in heart failure patients. The appearance of non-pitting ankle edema, although related to heart failure, is a more chronic and less urgent symptom when compared to a rapid weight gain, which requires immediate attention.
2. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.”
- B. “I’m interested in finding out more about how your body feels to you.”
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
- D. “It’s still too soon to expect to feel normal. Give it a little more time.”
Correct answer: B
Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.
3. What should the nurse include in the preoperative teaching for a 4-year-old child scheduled for a myringotomy?
- A. Explain the procedure in simple terms
- B. Encourage fluid intake
- C. Allow the child to play with medical equipment
- D. Use play therapy to prepare the child
Correct answer: A
Rationale: For a 4-year-old child scheduled for a myringotomy, explaining the procedure in simple terms is essential in helping the child understand what will happen during the surgery and reducing anxiety. Encouraging fluid intake, allowing the child to play with medical equipment, and using play therapy are not directly related to preparing the child for the myringotomy procedure. Therefore, these options are incorrect and not as beneficial as explaining the procedure in simple terms.
4. In the immediate postoperative period for a cleft lip repair in a 2-month-old infant, which nursing approach should be the priority?
- A. Remove protective arm devices one at a time for short periods with supervision
- B. Initiate oral feedings when alert
- C. Introduce the parents to the suture line cleansing protocol
- D. Position the infant on the back after feedings throughout the day
Correct answer: A
Rationale: The correct nursing approach in the immediate postoperative period for a cleft lip repair in an infant is to remove protective arm devices one at a time for short periods with supervision. This approach helps prevent injury to the surgical site while ensuring the infant's comfort and safety. Choice B is incorrect as initiating oral feedings immediately after surgery may not be appropriate and could compromise the surgical site. Choice C is incorrect as introducing parents to the suture line cleansing protocol is important but not the immediate priority. Choice D is incorrect as positioning the infant on the back after feedings is not specific to the immediate postoperative period for a cleft lip repair.
5. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?
- A. Increase wall suction while removing the suction catheter
- B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
- C. Suction the client’s oropharynx after tracheal suctioning
- D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter
Correct answer: D
Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.