HESI LPN
HESI Leadership and Management Test Bank
1. A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. You should contact the provider about your wishes for your family member.
- B. We'll need to have the nursing supervisor review the client's advance directives.
- C. You should speak with the facility's ethics committee about your concerns.
- D. As the health care surrogate, the client's partner can make this decision.
Correct answer: D
Rationale: The correct response is D because the health care surrogate, as designated by the client, has the legal authority to make healthcare decisions on behalf of the client when they are unable to do so. This authority includes decisions about treatment continuation or withdrawal. Option A is incorrect as the family member's wishes do not override the legal authority of the health care surrogate. Option B is not the most appropriate action in this situation as the advance directives are already clear by the designation of a health care surrogate. Option C is not necessary at this stage since the health care surrogate can make the decision without involving the ethics committee.
2. A postoperative client is reporting pain at a level of 2 on a scale of 0 to 10. What is an indication that the client understands pain management?
- A. It might help me to listen to music while lying in bed.
- B. I should try to sleep as much as possible to avoid pain.
- C. I don’t need pain medication if my pain is only at a 2.
- D. I will try to use the pain management techniques suggested by the nurse.
Correct answer: A
Rationale: The correct answer is A because understanding pain management involves considering non-pharmacological approaches, such as listening to music for relaxation and comfort. Choice B is incorrect as excessive sleep may not be an effective pain management strategy. Choice C is incorrect because pain medication may still be necessary even if pain levels are low. Choice D is not the best answer, as it simply states following the nurse’s suggestions without demonstrating an understanding of personalized pain management techniques.
3. The healthcare professional is assessing a client with a history of rheumatoid arthritis. Which of the following assessment findings would be most concerning?
- A. Morning stiffness
- B. Joint deformities
- C. Fever
- D. Weight loss
Correct answer: C
Rationale: In a client with rheumatoid arthritis, the presence of fever is most concerning because it may indicate an infection or systemic involvement, necessitating immediate attention. Morning stiffness and joint deformities are common manifestations of rheumatoid arthritis itself and are expected findings in these clients. Weight loss can occur in rheumatoid arthritis due to various factors such as decreased appetite or systemic inflammation, but it is not as acutely concerning as fever, which may signal a more urgent issue.
4. A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?
- A. Attempt to open the jaw.
- B. Place the child on the floor.
- C. Call out for assistance from staff.
- D. Place a pillow under the child’s head.
Correct answer: B
Rationale: The correct initial action during a tonic-clonic seizure is to place the child on the floor to prevent injury. This action helps protect the child from falling off the chair and provides a safer environment for the seizure to occur. Attempting to open the jaw can cause harm or injury. Calling out for assistance is important but should follow the immediate action of moving the child to the floor. Placing a pillow under the child’s head is not recommended as it may lead to airway obstruction or further injury during the seizure.
5. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?
- A. Pertussis, tetanus, polio, and measles
- B. Diphtheria, pertussis, tetanus, and polio
- C. Rubella, polio, tuberculosis, and pertussis
- D. Measles, mumps, rubella, and tuberculosis
Correct answer: B
Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.