HESI LPN
HESI Practice Test for Fundamentals
1. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:
- A. Ask the client if they are choking
- B. Perform abdominal thrusts
- C. Call for emergency help
- D. Check the client’s airway
Correct answer: A
Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.
2. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia for an unconscious client. What is the nurse's priority intervention?
- A. Measure the client's cardiac output
- B. Assess neurological status q15 min
- C. Collect a blood specimen for serum potassium
- D. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min
Correct answer: B
Rationale: The priority intervention for the nurse is to assess the client's neurological status q15 min. This is crucial to monitor for potential side effects of lidocaine, especially its neurotoxic effects. While measuring the client's cardiac output and collecting a blood specimen for serum potassium are important assessments, assessing the neurological status is the priority when administering lidocaine. Infusing lidocaine at a specific rate should follow the initial assessment of the client's neurological status to ensure safety.
3. You are managing a 10-month-old infant who has had severe diarrhea and vomiting for 3 days and is now showing signs of shock. You have initiated supplemental oxygen therapy and elevated the lower extremities. En route to the hospital, you note that the child's work of breathing has increased. What must you do first?
- A. Lower the extremities and reassess the child
- B. Begin positive pressure ventilations and reassess the child
- C. Place a nasopharyngeal airway and increase the oxygen flow
- D. Listen to the lungs with a stethoscope for abnormal breath sounds
Correct answer: A
Rationale: In this scenario, the infant is presenting with signs of respiratory distress, as evidenced by the increased work of breathing. Lowering the extremities can help reduce the workload on the diaphragm and improve respiratory mechanics. This action can be beneficial in optimizing the infant's breathing before considering more invasive interventions. Option B, initiating positive pressure ventilations, should be considered if the infant's condition deteriorates further and not as the first step. Option C, placing a nasopharyngeal airway and increasing oxygen flow, is not indicated as the primary intervention for increased work of breathing. Option D, listening to the lungs with a stethoscope, may provide additional information but is not the most urgent action needed in this situation.
4. Which best describes a full-thickness (third-degree) burn?
- A. Erythema and pain
- B. Skin showing erythema followed by blister formation
- C. Destruction of all layers of skin evident with extension into subcutaneous tissue
- D. Destruction injury involving underlying structures such as muscle, fascia, and bone
Correct answer: C
Rationale: A full-thickness (third-degree) burn involves the destruction of all layers of skin, including the epidermis, dermis, and extending into the subcutaneous tissue. This type of burn results in significant tissue damage and can appear pale, charred, or leathery. Choice A is incorrect as erythema and pain are more characteristic of superficial burns. Choice B describes a partial-thickness burn where the skin shows erythema followed by blister formation, involving the epidermis and part of the dermis. Choice D is incorrect as it describes a deeper type of injury involving structures beyond the skin layers, such as muscle, fascia, and bone, which is not specific to a full-thickness burn.
5. In a community health setting, which individual is at highest risk for contracting an HIV infection?
- A. 17-year-old who is sexually active with numerous partners
- B. 34-year-old homosexual in a monogamous relationship
- C. 30-year-old cocaine user who inhales and smokes drugs
- D. 45-year-old who has received two blood transfusions in the past 6 months
Correct answer: C
Rationale: The correct answer is C. Substance abuse, particularly using shared inhalation equipment like needles and pipes for drug inhalation, significantly increases the risk of contracting HIV. Choice A, the 17-year-old with multiple sexual partners, poses a risk of HIV transmission through sexual contact, but it is lower compared to the direct risk associated with sharing drug paraphernalia. Choice B, the 34-year-old homosexual in a monogamous relationship, is at lower risk since being in a monogamous relationship reduces exposure to HIV. Choice D, the 45-year-old who received blood transfusions, is also at lower risk as blood transfusions are now screened for HIV, decreasing the likelihood of transmission through this route.