HESI LPN
Practice HESI Fundamentals Exam
1. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?
- A. Complete an incident report
- B. Measure the client’s respiratory rate
- C. Report the incident to the pharmacy
- D. Notify the client's provider
Correct answer: B
Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.
2. When caring for a 7-week-old infant with hypothyroidism, the nurse explains that the prevention of what complication is dependent on the administration of oral thyroid replacement therapy and is critical for the child?
- A. Excessive growth
- B. Cognitive impairment
- C. Damage to the nervous system
- D. Damage to the urinary system
Correct answer: B
Rationale: The correct answer is B: Cognitive impairment. The treatment of choice for congenital and acquired hypothyroidism is oral thyroid hormone replacement therapy. Prompt treatment is especially critical in the infant with congenital hypothyroidism to avoid permanent cognitive impairment. Excessive growth (Choice A) is not a common complication of hypothyroidism in infants. Damage to the nervous system (Choice C) and damage to the urinary system (Choice D) are not typically associated with untreated hypothyroidism in infants.
3. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Secure the tube to the client's gown.
- C. Check the placement of the tube by auscultation.
- D. Irrigate the tube with normal saline every shift.
Correct answer: A
Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.
4. When performing cardiac chest compressions, what is a critical concept that the nurse must understand?
- A. Push hard and deep on the chest
- B. Compress the chest at a rapid rate
- C. Perform compressions with minimal interruptions
- D. Use a two-handed technique for compressions
Correct answer: A
Rationale: The correct answer is to 'Push hard and deep on the chest.' Effective chest compressions during CPR should be forceful and deep enough to adequately circulate blood to vital organs. This helps maintain perfusion and increases the likelihood of a successful outcome. Compressing the chest at a rapid rate (choice B) is important but not as critical as ensuring the compressions are hard and deep. Performing compressions with minimal interruptions (choice C) is also crucial to maintain blood flow. Using a two-handed technique for compressions (choice D) may be helpful but is not as critical as the depth and force of the compressions.
5. The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?
- A. Lethargy
- B. Urticaria
- C. Generalized rash
- D. Low-grade fever
Correct answer: D
Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.