HESI LPN
HESI Fundamentals Study Guide
1. A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
- A. Bladder scan shows 525 mL of urine
- B. Urine has a strong odor
- C. The client reports abdominal discomfort
- D. The catheter is blocked or not draining
Correct answer: D
Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.
2. During the immediate postoperative period following a total hip replacement, which intervention is most important for the nurse to implement?
- A. Encourage the client to use a walker or cane when ambulating
- B. Keep the client's hip aligned with knees abducted
- C. Teach the client to sit on the side of the bed before standing
- D. Monitor urinary flow via an indwelling catheter
Correct answer: B
Rationale: Keeping the client's hip aligned with the knees abducted is crucial to prevent dislocation of the prosthesis, which is a priority immediately after total hip replacement surgery. This position helps maintain the stability of the new hip joint. Encouraging the client to use a walker or cane (Choice A) is important but not as critical as ensuring proper hip alignment. Teaching the client to sit on the side of the bed before standing (Choice C) is a good practice but not as essential as maintaining hip alignment. Monitoring urinary flow via an indwelling catheter (Choice D) is not directly related to preventing complications immediately after a total hip replacement.
3. A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?
- A. Hypotension
- B. Weight gain
- C. Dry mouth
- D. Tachycardia
Correct answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.
4. The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
- A. Leave the order for the oncoming staff to follow up
- B. Contact the charge nurse for an interpretation
- C. Ask the pharmacy for assistance in interpretation
- D. Call the provider for clarification
Correct answer: D
Rationale: The nurse should call the provider for clarification. In situations where there is difficulty reading an order, it is crucial to directly contact the healthcare provider to ensure the correct order is understood and followed. Leaving the order for the oncoming staff (Choice A) may lead to misunderstandings and errors. Contacting the charge nurse (Choice B) may cause delays as they may also need to contact the provider. Asking the pharmacy (Choice C) is not the most direct and immediate action in this scenario, as the provider is the one who can provide immediate clarification.
5. The family presents several problems. Which of the following criteria is considered in determining the priority health problem?
- A. expected consequence of the problem
- B. cooperation and support of the family
- C. involvement of the family members in the problem
- D. modifiability of the problem
Correct answer: D
Rationale: When determining the priority health problem within a family, one key criterion to consider is the modifiability of the problem. This means assessing whether the health issue can be changed or improved through interventions. Choices A, B, and C are not directly related to the priority of the health problem within the family. The expected consequence of the problem, cooperation and support of the family, and involvement of family members are important factors but do not specifically address the priority of the health issue based on modifiability.