HESI LPN
HESI Fundamentals Test Bank
1. A healthcare professional in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. Which of the following findings should the healthcare professional identify as an indication that the client has an infection?
- A. WBC 15,000/mm³
- B. Hemoglobin 12 g/dL
- C. Platelet count 300,000/mm³
- D. Sodium 140 mEq/L
Correct answer: A
Rationale: An elevated white blood cell count (WBC 15,000/mm³) is a common indicator of infection as the body increases WBC production to fight off pathogens. In conditions like infections, inflammation, or stress, the WBC count can rise. The other options, hemoglobin, platelet count, and sodium levels, are not typically specific indicators of infection. Hemoglobin measures the oxygen-carrying capacity of red blood cells, platelet count assesses clotting ability, and sodium levels indicate electrolyte balance.
2. A client scheduled for arthroplasty expresses concern about the risk of acquiring an infection from a blood transfusion. Which of the following statements should the nurse make to the client?
- A. Donate autologous blood before the surgery
- B. Request a specific blood type from the donor
- C. Use blood from a family member
- D. Accept allogeneic blood without concerns
Correct answer: A
Rationale: The correct statement for the nurse to make to the client is to 'Donate autologous blood before the surgery.' Autologous blood donation involves collecting and storing the client's own blood for potential use during surgery, which significantly reduces the risk of transfusion-related infections. This option directly addresses the client's concern about infection risk. Requesting a specific blood type from a donor (Choice B) is not as effective in reducing infection risk compared to autologous blood donation. Using blood from a family member (Choice C) carries the risk of transfusion reactions and infections due to compatibility issues. Accepting allogeneic blood without concerns (Choice D) does not address the client's specific concern about infection risk and is not the most appropriate option in this situation.
3. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?
- A. Obtain a specimen for culture.
- B. Apply a warm compress.
- C. Administer analgesics.
- D. Discontinue the infusion.
Correct answer: D
Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.
4. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?
- A. Ensure the client wears a mask when outside the room if there is construction nearby.
- B. Place the client in a private room with positive pressure airflow.
- C. Restrict all visitors from seeing the client.
- D. Provide a HEPA filter in the client's room.
Correct answer: A
Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.
5. A client has a sodium level of 125. What findings should the nurse expect?
- A. Abdominal cramping
- B. Elevated blood pressure
- C. Decreased heart rate
- D. Increased thirst
Correct answer: A
Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.
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