HESI LPN
Fundamentals HESI
1. A client has a sodium level of 125. What findings should the nurse expect?
- A. Abdominal cramping
- B. Elevated blood pressure
- C. Decreased heart rate
- D. Increased thirst
Correct answer: A
Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.
2. The healthcare provider is assessing a client with acute pancreatitis. Which finding is most concerning?
- A. Pain radiating to the back
- B. Blood pressure of 95/60 mmHg
- C. Elevated serum amylase
- D. Absent bowel sounds
Correct answer: B
Rationale: In acute pancreatitis, a low blood pressure of 95/60 mmHg is the most concerning finding as it may indicate hypovolemia or shock, which are critical conditions requiring immediate intervention. Pain radiating to the back is a common symptom of pancreatitis but is not as immediately life-threatening as hypotension. Elevated serum amylase levels and absent bowel sounds are typical findings in acute pancreatitis and may indicate pancreatic inflammation and gastrointestinal motility issues, respectively, but they are not as acutely concerning as hypotension.
3. A 2-year-old child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?
- A. Avoid spicy foods
- B. Avoid gluten
- C. Avoid high-fat foods
- D. Avoid dairy products
Correct answer: B
Rationale: The correct dietary instruction for a 2-year-old child with GERD is to avoid gluten. Gluten is a protein found in wheat, barley, and rye that can worsen GERD symptoms. Avoiding gluten can help reduce inflammation and discomfort in the esophagus. Choices A, C, and D are incorrect because spicy foods, high-fat foods, and dairy products can exacerbate GERD symptoms. Spicy foods can irritate the esophagus, high-fat foods delay stomach emptying leading to increased acid reflux, and dairy products can stimulate acid production, all of which can worsen GERD symptoms.
4. A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?
- A. Bend at the knees while maintaining a wide stance and a straight back, with the client’s hands on the nurse’s shoulders, and the nurse’s hands under the client’s axillae
- B. Use a mechanical lift
- C. Twist at the waist while holding the client
- D. Ask for assistance from another staff member
Correct answer: A
Rationale: The correct technique for transferring a client from a bed to a chair to avoid back injuries is to bend at the knees while maintaining a wide stance and a straight back. This position ensures that the nurse uses leg muscles rather than the back muscles for lifting, reducing the risk of injury. Placing the client’s hands on the nurse’s shoulders and the nurse’s hands under the client’s axillae provides additional support and stability during the transfer. Using a mechanical lift may be appropriate for certain situations but is not necessary for a simple bed-to-chair transfer. Twisting at the waist while holding the client can lead to back strain or injury. Asking for assistance from another staff member is a good practice, but proper body mechanics should still be followed to ensure safe client handling.
5. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?
- A. Decrease in heart rate
- B. Fluid volume deficit causes tachycardia
- C. Decrease in blood pressure
- D. Increase in respiratory rate
Correct answer: A
Rationale: A decrease in heart rate can indicate that the fluid volume deficit is improving. In cases of fluid volume deficit, the body compensates by increasing the heart rate to maintain adequate perfusion. Therefore, a decrease in heart rate after fluid resuscitation suggests that the body's perfusion status is improving. Choices B, C, and D are incorrect because fluid volume deficit typically causes tachycardia, not a decrease in heart rate, and would not result in a decrease in blood pressure or an increase in respiratory rate as primary signs of improvement.