HESI LPN
HESI Fundamentals Study Guide
1. A healthcare provider in an office is preparing to auscultate and percuss a client’s thorax as part of a comprehensive physical examination. Which of the following findings should the provider expect?
- A. Rhonchi
- B. Crackles
- C. Resonance
- D. Tactile fremitus
Correct answer: C
Rationale: During a thoracic examination, normal findings should include resonance, which is the expected sound when percussing the thorax. Resonance indicates healthy lung tissue and air-filled spaces. Abnormal findings such as rhonchi and crackles suggest issues like lung congestion or inflammation. Tactile fremitus refers to vibrations felt on the chest wall during palpation and is not typically assessed during percussion and auscultation of the thorax.
2. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:
- A. Check the client’s identification bracelet
- B. Inform the client about the procedure
- C. Prepare the client for transport
- D. Verify the x-ray order
Correct answer: A
Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.
3. A middle-aged adult in a clinical setting mentions being at average risk for colon cancer and asks about routine screening. What should the nurse recommend?
- A. Performing a blood sample for a screening test.
- B. Scheduling a colonoscopy starting at age 60.
- C. Undergoing a fecal occult blood test annually.
- D. Having a sigmoidoscopy every 10 years.
Correct answer: C
Rationale: The correct answer is C. Colorectal cancer screening for individuals at average risk typically begins at age 50. One of the recommended options for routine screening is a fecal occult blood test done annually. Choice A is incorrect as blood samples are not used for routine colorectal cancer screening. Choice B is incorrect because colonoscopies usually start at age 50, not 60. Choice D is incorrect as sigmoidoscopies are recommended every 5 years, not every 10 years, for individuals at average risk for colon cancer.
4. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.
5. Which action should be taken to assess for analgesic tolerance in a client who is unable to communicate?
- A. Review the client's laboratory values for changes in peak and trough levels of the analgesic
- B. Prolong the interval between analgesic medication doses and monitor the client's vital signs
- C. Observe the client for the presence of pain behaviors before the next analgesic dose is due
- D. Ask family members to report behaviors suggesting that the client's pain has returned
Correct answer: C
Rationale: In clients who are unable to communicate, observing for pain behaviors is crucial in assessing analgesic tolerance. Changes in pain behaviors can indicate if the current analgesic regimen is effective or if tolerance has developed. Therefore, closely observing the client for pain behaviors before the next analgesic dose helps healthcare providers evaluate the client's response to pain management. Reviewing laboratory values may not directly reflect analgesic tolerance. Prolonging the interval between doses and monitoring vital signs may not provide direct information on analgesic tolerance. Relying solely on family members to report pain behaviors may not be as accurate or immediate as observing the client directly.