HESI LPN
Practice HESI Fundamentals Exam
1. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain radiate to other areas?
- C. Does the pain increase with movement?
- D. Can you rate your pain on a scale of 1 to 10?
Correct answer: A
Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.
2. A nurse is reviewing the laboratory report of a child with tetralogy of Fallot that indicates an elevated RBC count. What does the nurse identify as the cause of the polycythemia?
- A. Low tissue oxygen needs
- B. Tissue oxygen needs
- C. Diminished iron levels
- D. Hypertrophic cardiac muscle
Correct answer: B
Rationale: The correct answer is B: Tissue oxygen needs. Polycythemia occurs in response to chronic hypoxia, leading the body to increase red blood cell production to enhance oxygen delivery. In tetralogy of Fallot, a congenital heart defect that results in reduced oxygen levels in the blood, the body compensates by producing more red blood cells. Choice A is incorrect as low tissue oxygen needs would not trigger polycythemia. Choice C, diminished iron levels, is not the cause of polycythemia in this case. Choice D, hypertrophic cardiac muscle, is unrelated to the pathophysiology of polycythemia in tetralogy of Fallot.
3. A client with major depressive disorder is prescribed bupropion. Which statement by the client indicates the need for further teaching?
- A. This medication may cause weight gain.
- B. This medication may take several weeks to take effect.
- C. I should avoid alcohol while taking this medication.
- D. I should take this medication in the morning with food.
Correct answer: A
Rationale: The correct answer is A because bupropion is associated with weight loss rather than weight gain. It is important for the client to be aware of this potential side effect. Choice B is correct because bupropion may take several weeks to exhibit its full therapeutic effects. Choice C is also accurate as alcohol consumption should be avoided while taking bupropion due to the risk of seizures. Choice D is correct as taking bupropion in the morning with food can help reduce the risk of gastrointestinal side effects.
4. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred?
- A. Is worried about losing his job to a woman
- B. Tortured animals as a child
- C. Was physically abused by his mother
- D. Hates to be touched by anyone
Correct answer: C
Rationale: The correct answer is C: 'Was physically abused by his mother.' A history of physical abuse can lead to heightened responses to physical contact. In this scenario, the employee's reaction of becoming very angry and swinging at the female employee after being pushed may be influenced by past experiences of physical abuse. This history can contribute to increased sensitivity to physical interactions and may trigger defensive or aggressive responses. Choices A, B, and D are less directly related to the employee's reaction in this specific context. While worrying about losing his job to a woman could contribute to underlying stress or insecurity, torturing animals as a child reflects a different type of behavioral issue, and hating to be touched by anyone suggests personal boundaries unrelated to the observed behavior in this scenario.
5. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP), and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
- A. An admission at the change of shifts with atrial fibrillation and heart failure - PN
- B. Client who had a major stroke 6 days ago - PN nursing student
- C. A child with burns who has packed cells and albumin IV running - charge nurse
- D. An elderly client who had a myocardial infarction a week ago - UAP
Correct answer: A
Rationale: Assigning an admission with atrial fibrillation and heart failure to a PN is not appropriate. This complex case requires more advanced skills and should not be managed by a PN without adequate support. The PN may not have the necessary training or expertise to handle such a critical situation effectively. Choice B is a suitable assignment for a PN nursing student as they can handle a client who had a major stroke 6 days ago. Choice C is also appropriate as a child with burns receiving packed cells and albumin IV running can be managed by the charge nurse. Choice D is within the scope of practice for a UAP since an elderly client post-myocardial infarction a week ago may require basic care and assistance.