HESI LPN
HESI Fundamentals Exam Test Bank
1. While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?
- A. Swelling and coolness are observed at the IV site.
- B. The client reports mild discomfort at the insertion site.
- C. The infusion rate is slower than expected.
- D. The IV catheter is no longer needed for treatment.
Correct answer: A
Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.
2. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?
- A. Information regarding shelters
- B. Instructions regarding calling the police
- C. Instructions regarding self-defense classes
- D. Explaining the importance of leaving the violent situation
Correct answer: A
Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.
3. What is the most common sign of a localized infection?
- A. Fever
- B. Elevated white blood cell count
- C. Redness, warmth, and swelling at the site of infection
- D. Chills and shivering
Correct answer: C
Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.
4. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for further evaluation and possible intervention?
- A. A client who is at 28 weeks gestation and has a negative Coombs titer
- B. A client who is 39 weeks of gestation and has a negative contraction stress test
- C. A client who is at 35 weeks of gestation and has a biophysical profile of 6
- D. A client who is at 37 weeks of gestation and has an L/S ratio of 2:1
Correct answer: C
Rationale: A biophysical profile of 6 at 35 weeks of gestation indicates a need for further evaluation and possible intervention. A negative Coombs titer at 28 weeks gestation (Choice A) is within normal limits. A negative contraction stress test at 39 weeks gestation (Choice B) is expected as the pregnancy nears term. An L/S ratio of 2:1 at 37 weeks of gestation (Choice D) is consistent with fetal lung maturity.
5. Which of the following statements is not correct regarding family planning?
- A. Family planning services should be made available to those who need them.
- B. It is the responsibility of every parent to determine whether to have children, when, or how many.
- C. Family planning is geared towards individual and family welfare.
- D. The ultimate goal of family planning is to prevent pregnancies.
Correct answer: D
Rationale: The correct answer is D because the ultimate goal of family planning is not solely to prevent pregnancies but to promote individual and family well-being. Family planning encompasses various aspects such as helping individuals and families make informed choices about the number and spacing of their children, access to healthcare services, and overall reproductive health. Option A is correct as making family planning services available to those who need them is essential for promoting reproductive health. Option B is also correct as it emphasizes the role of parents in making decisions about having children. Option C is correct as family planning indeed aims to improve the welfare of individuals and families. Therefore, option D is not correct as the ultimate goal of family planning is not limited to preventing pregnancies, but it includes broader aspects of promoting health and well-being.