HESI LPN
HESI Fundamentals Test Bank
1. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?
- A. Apply the stockings with the creases on the front of the leg.
- B. Apply the stockings while the client's legs are in a dependent position.
- C. Remove the stockings at least once per shift.
- D. Remove the stockings while the client is sitting in a reclining chair.
Correct answer: C
Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.
2. A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct answer: D
Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.
3. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?
- A. Stand to the side of the patient's eye and observe the cornea.
- B. Conclude that the glasses were lost during the accident.
- C. Notify the ambulance personnel about the missing glasses.
- D. Ask the patient where the glasses are.
Correct answer: A
Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.
4. What should be done when caring for a client who died?
- A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
- B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
- C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
- D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.
Correct answer: A
Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.
5. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?
- A. After the acute phase of the disease has passed.
- B. As soon as the ability to move is lost.
- C. Once the patient enters the rehab unit.
- D. When the patient requests it.
Correct answer: B
Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.
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