HESI LPN
HESI Practice Test for Fundamentals
1. When assessing the skin of an immobilized patient, what should the nurse do?
- A. Assess the skin every 4 hours.
- B. Limit the amount of fluid intake.
- C. Use a standardized tool such as the Braden Scale.
- D. Have special times for inspection to not interrupt routine care.
Correct answer: C
Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.
2. A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
- A. “I spent my whole life dreaming about retirement, and now I wish I had my job back.”
- B. “It’s been so stressful for me to have to depend on my child to help around the house.”
- C. “I just heard my friend Al die. That’s the third one in 3 months.”
- D. “I keep forgetting which medications I have taken during the day.”
Correct answer: C
Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.
3. A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?
- A. Heart rate and blood pressure
- B. Blood glucose levels
- C. Respiratory rate
- D. Liver function tests
Correct answer: A
Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.
4. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?
- A. Take the medication on an empty stomach.
- B. Avoid drinking alcohol while taking this medication.
- C. This medication may cause drowsiness, so avoid driving.
- D. You can stop taking the medication once you feel better.
Correct answer: B
Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.
5. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?
- A. Nurse will check client q1h for the presence of chest pain
- B. Client has a nervous, tense personality and is likely to overreact
- C. Client states he will notify the nurse if chest pain returns
- D. Client understands how to use the call button and the telephone
Correct answer: C
Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.