HESI LPN
HESI Fundamental Practice Exam
1. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
- A. 2 cups of soup
- B. 1 quart of water
- C. 8 oz of ice chips
- D. 6 oz of tea
Correct answer: C
Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.
2. A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What should the nurse recommend the parent to do?
- A. Administer syrup of ipecac.
- B. Call the poison control center.
- C. Take the child to the emergency department.
- D. Give the child bread dipped in milk to absorb the poison.
Correct answer: B
Rationale: In cases of potential poisoning, immediate guidance from professionals is crucial. Administering syrup of ipecac is no longer recommended routinely due to potential risks and lack of benefit. Taking the child to the emergency department is necessary in severe cases but may not always be the immediate action needed. Giving the child bread dipped in milk is not an appropriate method to manage poisoning and could potentially worsen the situation. Therefore, the most appropriate action for the nurse to recommend is to call the poison control center for expert advice on managing the situation.
3. A client with a history of heart failure is prescribed carvedilol. The nurse should monitor for which potential side effect?
- A. Bradycardia
- B. Tachycardia
- C. Hypertension
- D. Hyperglycemia
Correct answer: A
Rationale: When a client is prescribed carvedilol, the nurse should monitor for bradycardia, a potential side effect of this medication. Carvedilol is a beta-blocker that can slow down the heart rate, so monitoring for signs of bradycardia is essential to prevent any adverse effects on the client's cardiovascular system. Tachycardia (Choice B) is less likely to occur with carvedilol since it primarily works to reduce heart rate. Hypertension (Choice C) and hyperglycemia (Choice D) are not common side effects associated with carvedilol.
4. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?
- A. Ask the wife how she would like to participate in the client's care
- B. Provide the wife with information about hospice
- C. Encourage the wife to visit during the treatment process
- D. Refer her to a support group for family members of those with terminal cancer
Correct answer: A
Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.
5. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is
- A. prone.
- B. Fowler's.
- C. Sims'.
- D. supine.
Correct answer: B
Rationale: Fowler's position is the optimal position for a client receiving tube feedings via a gastrostomy tube because it reduces the risk of aspiration. In Fowler's position, the client is sitting up at a 45- to 60-degree angle, which helps prevent the formula from flowing back into the esophagus and causing aspiration pneumonia. Choice A, prone position (lying face down), would not be suitable for administering tube feedings as it increases the risk of aspiration. Sims' position (lying on the left side with the right knee flexed) and supine position (lying flat on the back) are also not ideal for administering tube feedings as they do not provide the same level of protection against aspiration as Fowler's position does.