HESI LPN
HESI Fundamentals Study Guide
1. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
- A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
- B. Pinch the skin on the back of the hand and observe for elasticity
- C. Assess the skin turgor on the abdomen by pinching the skin
- D. Check the skin turgor by pressing on the forearm and observing the rebound
Correct answer: A
Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.
2. As a community health nurse covering a cluster of Barangays, your population coverage includes the following:
- A. Families in their homes, School population, Workers in factories
- B. Families in their homes, School population, Patients in hospital
- C. All except workers in factories
- D. All except patients in hospital
Correct answer: A
Rationale: The correct answer is A: 'Families in their homes, School population, Workers in factories.' As a community health nurse, you are responsible for providing healthcare services and promoting health within the community. This includes visiting families in their homes to assess their health needs, working with the school population to educate them on preventive health measures, and ensuring the health and safety of workers in factories. Choices B, C, and D are incorrect because they do not encompass the full scope of a community health nurse's responsibilities. Choice B does not include workers in factories, Choice C excludes an important population group, and Choice D excludes an essential setting where healthcare services are provided.
3. While changing the linen on the client's bed, what should the nurse do?
- A. Hold the linen away from their body and clothing.
- B. Fold the linen neatly before placing it in the laundry.
- C. Wear clean gloves while handling the linen.
- D. Place the linen directly on the floor until the new linen is in place.
Correct answer: A
Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.
4. The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.
5. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?
- A. Check the blood glucose level
- B. Administer insulin immediately
- C. Offer a high-protein snack
- D. Place the client in a supine position
Correct answer: A
Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.