HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?
- A. Commend the client for selecting a high biological value protein.
- B. Remind the client that protein in the diet should be avoided.
- C. Suggest that the client also select orange juice to promote absorption.
- D. Encourage the client to attend classes on dietary management of chronic renal failure.
Correct answer: A
Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.
2. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?
- A. Check the placement of the NG tube
- B. Flush the tube with saline
- C. Position the client in a semi-Fowler's position
- D. Administer the medication slowly
Correct answer: A
Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.
3. In a client with liver cirrhosis, which symptom would be most concerning during assessment?
- A. Jaundice
- B. Ascites
- C. Hepatomegaly
- D. Altered mental status
Correct answer: D
Rationale: Altered mental status would be the most concerning symptom in a client with liver cirrhosis. It may indicate hepatic encephalopathy, a serious complication requiring immediate intervention. While jaundice, ascites, and hepatomegaly are common in liver cirrhosis, they do not directly correlate with the urgency and severity of hepatic encephalopathy as altered mental status does. Therefore, altered mental status takes priority for immediate attention and intervention.
4. What is the first action to take before administering tube feeding to an infant?
- A. Irrigate the tube with water.
- B. Offer a pacifier to the infant.
- C. Slowly instill 10 mL of formula.
- D. Place the infant in the Trendelenburg position.
Correct answer: B
Rationale: The correct first action before administering tube feeding to an infant is to offer a pacifier. Providing a pacifier stimulates the sucking reflex, aiding in digestion and providing comfort to the infant. Irrigating the tube with water (Choice A) is not typically the initial step and could potentially introduce unnecessary fluid into the infant's system. Slowly instilling formula (Choice C) should only be done after ensuring the tube is appropriately placed. Placing the infant in the Trendelenburg position (Choice D) is not necessary for tube feeding and could pose risks such as aspiration.
5. What explanation should be given to a parent about the purpose of a tetanus toxoid injection for their child?
- A. Passive immunity is conferred for life.
- B. Long-lasting active immunity is conferred.
- C. Lifelong active natural immunity is conferred.
- D. Passive natural immunity is conferred temporarily.
Correct answer: B
Rationale: The correct answer is B: 'Long-lasting active immunity is conferred.' Tetanus toxoid injection provides long-lasting active immunity by stimulating the body to produce its own antibodies. Choice A is incorrect because tetanus toxoid injection does not provide passive immunity. Choice C is incorrect because the immunity conferred by the vaccine is not natural but artificially induced. Choice D is incorrect as the immunity provided by the tetanus toxoid injection is active, not passive.