HESI LPN
Fundamentals of Nursing HESI
1. During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?
- A. Thin, parchment-like skin
- B. Loss of adipose tissue
- C. Dehydration
- D. Diminished skin elasticity
Correct answer: C
Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.
2. As the new PHN in barangay Masinag, what is necessary to conduct in order to get a picture of the health and social status of the community?
- A. Mass information campaign
- B. Home visit
- C. Community assembly
- D. Community health survey
Correct answer: D
Rationale: To accurately assess the health and social status of a community, conducting a community health survey is essential. This method provides a comprehensive and systematic way to gather data on various health indicators and social determinants within the community. Choices A, B, and C are not as effective in providing a holistic view of the community's health and social status. A mass information campaign may raise awareness but lacks in-depth data collection, a home visit focuses on individual households rather than the entire community, and a community assembly may not reach all community members or provide structured data collection.
3. The healthcare provider is planning care for a client at 30 weeks gestation who is experiencing preterm labor. Which medication is most important in preventing this fetus from developing respiratory distress syndrome?
- A. Ampicillin 1 gram IV push every 8 hours
- B. Betamethasone 12 mg deep IM
- C. Terbutaline 0.25 mg subcutaneously every 15 minutes for 3 doses
- D. Butorphanol tartrate 1 mg IV push every 2 hours as needed
Correct answer: B
Rationale: Betamethasone is a corticosteroid given to stimulate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Ampicillin (Choice A) is an antibiotic and does not prevent respiratory distress syndrome. Terbutaline (Choice C) is a tocolytic used to inhibit contractions and does not directly prevent respiratory distress syndrome. Butorphanol tartrate (Choice D) is an opioid analgesic and does not have a role in preventing respiratory distress syndrome in preterm infants.
4. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take?
- A. Explain that the symptoms are caused by liver damage and can be managed
- B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief
- C. Encourage the client to use cooler water and apply oil-based lotion after soaking
- D. Suggest that the client take brief showers and apply oil-based lotion after showering
Correct answer: D
Rationale: Cooler water and oil-based lotion can help relieve pruritus and improve comfort in clients with cirrhosis experiencing jaundice and pruritus. Hot baths can exacerbate itching, so it is important to suggest cooler showers instead. Choice A is incorrect because symptoms like pruritus can be managed. Choice B is not the most appropriate initial intervention for pruritus related to liver disease. Choice C suggests the use of calamine lotion, which may not be as effective as oil-based lotion for relieving pruritus in this case.
5. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?
- A. Mechanical ventilation
- B. Platelet transfusion
- C. Loop diuretic therapy
- D. Cyanocobalamin administration
Correct answer: A
Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.