HESI LPN
HESI Fundamentals Practice Questions
1. A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Abdominal cramping
- B. Increased thirst
- C. Elevated blood pressure
- D. Elevated heart rate
Correct answer: A
Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.
2. What intervention should the nurse implement for a client experiencing an anxiety attack?
- A. Teach deep breathing exercises
- B. Provide a quiet environment
- C. Administer anxiolytic medication as prescribed
- D. Engage the client in conversation
Correct answer: C
Rationale: Administering prescribed anxiolytic medication is the most appropriate intervention for a client experiencing an anxiety attack. Anxiolytic medications can provide rapid relief from severe anxiety symptoms. Teaching deep breathing exercises (choice A) can be helpful for managing mild anxiety but may not be sufficient during an acute anxiety attack. Providing a quiet environment (choice B) is beneficial to reduce stimuli, but it may not address the immediate distress of an ongoing anxiety attack. Engaging the client in conversation (choice D) is generally not recommended during an anxiety attack as it can potentially exacerbate the symptoms by increasing stimulation.
3. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?
- A. A Rh-negative mother who has an Rh-positive infant
- B. A Rh-positive mother who has an Rh-negative infant
- C. A Rh-positive mother who has an Rh-positive infant
- D. A Rh-negative mother who has an Rh-negative infant
Correct answer: A
Rationale: The correct answer is A: 'A Rh-negative mother who has an Rh-positive infant.' In cases where the newborn is born post-term, the mismatched Rh factor between the mother (Rh-negative) and the infant (Rh-positive) can lead to hemolytic disease of the newborn. This condition occurs when maternal antibodies attack fetal red blood cells, causing hemolysis. This can result in jaundice, anemia, and other serious complications for the infant. Choices B, C, and D are incorrect because they do not reflect the mismatched Rh factor scenario that poses a risk for hemolytic disease of the newborn.
4. What is the most common cause of vaginal bleeding immediately after birth?
- A. Uterine atony
- B. Genital lacerations
- C. Abnormal clotting mechanism
- D. Endometritis
Correct answer: A
Rationale: Vaginal bleeding immediately after birth is most often due to uterine atony, which is the failure of the uterus to contract following delivery. This results in inadequate compression of blood vessels at the placental site, leading to hemorrhage. Genital lacerations and abnormal clotting mechanisms can also cause bleeding but are less common immediately after birth compared to uterine atony. Endometritis, inflammation of the lining of the uterus, usually presents with symptoms like fever and pelvic pain rather than immediate postpartum bleeding.
5. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
- A. Remove the cap and apply direct gentle pressure with the syringe
- B. Contact the healthcare provider regarding the need for a chest x-ray
- C. Cover the cap with tape and label the port as being obstructed
- D. Remove the catheter while applying gentle pressure at the insertion site
Correct answer: B
Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.