HESI LPN
HESI Fundamentals Exam Test Bank
1. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?
- A. Administer pain medication 45 minutes before changing the client’s dressing.
- B. Change the dressing less frequently.
- C. Apply a topical anesthetic before removing the dressing.
- D. Use a non-adherent dressing to reduce pain.
Correct answer: A
Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.
2. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?
- A. Check the placement of the tube by auscultation.
- B. Flush the tube with 30 ml of water before and after medication administration.
- C. Administer the medication with food to prevent nausea.
- D. Dilute the medication with normal saline before administration.
Correct answer: B
Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.
3. A client with an aggressive form of prostate cancer declines to discuss concerns after the provider briefly discusses treatment options and leaves the room. Which of the following statements should the nurse make?
- A. “I am available to talk if you should change your mind.”
- B. “I understand you do not want to discuss it further.”
- C. “You should talk to the provider if you have more questions.”
- D. “I will be back later to discuss your concerns.”
Correct answer: A
Rationale: The nurse should offer support without pressuring the client. Stating, “I am available to talk if you should change your mind,” acknowledges the client's decision while leaving the door open for future discussions. Choice B is incorrect as it assumes the client's decision is final without offering further support. Choice C directs the client back to the provider without addressing the nurse's availability. Choice D commits to a future discussion without considering the client's current preference.
4. During assessment, what is a nurse monitoring when assessing body alignment?
- A. The relationship of one body part to another in different positions
- B. The coordination between musculoskeletal and nervous systems
- C. The force opposing movement direction
- D. The ability to move freely
Correct answer: A
Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.
5. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
- A. Use the planning step of the nursing process to prioritize client care delivery.
- B. Delegate all tasks to assistive personnel.
- C. Focus on completing tasks in the order they are assigned.
- D. Avoid using a checklist for daily tasks.
Correct answer: A
Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.
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