HESI LPN
HESI Fundamentals Test Bank
1. A client with type 2 diabetes mellitus is receiving metformin (Glucophage). Which laboratory test should the LPN/LVN monitor while the client is taking this medication?
- A. Complete blood count (CBC)
- B. Liver function tests
- C. Serum electrolytes
- D. Renal function tests
Correct answer: B
Rationale: The correct answer is B: Liver function tests. While a client is taking metformin, monitoring liver function tests is crucial to assess for potential hepatic side effects. Metformin is primarily eliminated by the liver, and monitoring liver function tests helps in early detection of any liver-related complications. Choices A, C, and D are incorrect. A complete blood count (CBC) is not specifically required for monitoring metformin therapy. Serum electrolytes are not directly impacted by metformin, making it less relevant for monitoring this medication. Renal function tests are important for some other diabetes medications, but in the case of metformin, liver function tests take precedence due to its hepatic metabolism.
2. The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?
- A. Lethargy
- B. Urticaria
- C. Generalized rash
- D. Low-grade fever
Correct answer: D
Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.
3. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
- A. Mood swings.
- B. Extreme sadness.
- C. Manipulative behavior.
- D. Flat affect.
Correct answer: D
Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.
4. While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
- A. Flexion of lower extremities
- B. Negative Ortolani response
- C. Lengthened leg of affected side
- D. Irregular hip symmetry
Correct answer: D
Rationale: Irregular hip symmetry, such as asymmetry in the gluteal folds, is a common sign of hip dislocation in newborns. This finding indicates a potential abnormality in hip development and requires further evaluation and possible treatment. Choices A, B, and C are incorrect. Flexion of lower extremities is a normal newborn reflex, the Ortolani response is used to detect hip dysplasia rather than hip dislocation, and a lengthened leg of the affected side is not typically associated with hip dislocation in newborns.
5. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct answer: A
Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.