HESI LPN
HESI Fundamentals 2023 Quizlet
1. A client in the emergency department is being cared for by a nurse and has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
- A. Tachycardia
- B. Elevated blood pressure
- C. Warm, dry skin
- D. Decreased respiratory rate
Correct answer: A
Rationale: Tachycardia is a hallmark sign of hypovolemic shock. When a client experiences significant blood loss, the body compensates by increasing the heart rate to maintain adequate perfusion to vital organs. Elevated blood pressure is not typically seen in hypovolemic shock; instead, hypotension is a more common finding. Warm, dry skin is characteristic of neurogenic shock, not hypovolemic shock. Decreased respiratory rate is not a typical manifestation of hypovolemic shock, as the body usually tries to increase respiratory effort to improve oxygenation in response to hypovolemia.
2. The nurse is calculating the one-minute Apgar score for a newborn male infant and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant?
- A. 8
- B. 9
- C. 6
- D. 7
Correct answer: A
Rationale: The correct answer is A: 8. The Apgar score is calculated based on five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a good heart rate, vigorous cry, good muscle tone, and quick reflex irritability, which would total to 8. The only factor affecting the score is the cyanotic color, which could indicate potential respiratory or circulatory issues. Choices B, C, and D are incorrect as they do not reflect the overall assessment provided in the scenario.
3. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?
- A. Tie the restraint with a quick-release knot.
- B. Use a slipknot to secure the restraint.
- C. Ensure the restraint is tightly secured.
- D. Attach the restraint to the bed frame.
Correct answer: A
Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.
4. The nurse manager has a nurse employee who is suspected of having a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct answer: C
Rationale: Consulting with human resources is the best approach in this situation. It ensures that the issue is handled according to the organization's policies and that the nurse receives the appropriate support and intervention needed for chemical dependency. Confronting the nurse directly may lead to defensiveness and hinder a constructive resolution. Scheduling a staff conference without the nurse present can create unnecessary speculation and violate the employee's privacy. Counseling the employee to resign is not appropriate and does not address the underlying problem of chemical dependency.
5. The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?
- A. Applesauce
- B. White rice
- C. Coffee
- D. Bananas
Correct answer: C
Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.