HESI LPN
HESI Fundamentals Exam Test Bank
1. When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
- A. Press gently on the tragus of the client’s ear.
- B. Pull the ear lobe up and back.
- C. Insert the medication deeply into the ear canal.
- D. Massage the ear gently after administering the medication.
Correct answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client’s ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.
2. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.
3. A client has a new diagnosis of hypothyroidism. Which of the following interventions should the nurse include in the plan of care?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Increase iodine intake.
Correct answer: B
Rationale: The correct intervention for a client with hypothyroidism is to encourage frequent rest periods. Hypothyroidism often leads to fatigue, making rest essential for recovery and symptom management. Providing a high-calorie diet is not necessary unless the client has gained weight due to hypothyroidism. Restricting fluid intake is not indicated unless there are specific medical reasons for it. Increasing iodine intake is not recommended for primary hypothyroidism, as it is typically caused by autoimmune thyroiditis or other factors rather than iodine deficiency.
4. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:
- A. Share personal beliefs
- B. Encourage the client to express their thoughts about death and dying
- C. Redirect the conversation to medical treatment
- D. Inform the client that the nurse’s beliefs are not relevant
Correct answer: B
Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.
5. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?
- A. Increased urine output
- B. Decreased blood pressure
- C. Increased heart rate
- D. Increased respiratory rate
Correct answer: B
Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.
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