HESI LPN
Fundamentals of Nursing HESI
1. When changing a client's colostomy pouch and noticing peristomal skin irritation, which of the following actions should the nurse take?
- A. Change the pouch as needed based on individual requirements.
- B. Apply the pouch only when the skin barrier is completely dry.
- C. Pat the peristomal skin dry after cleaning.
- D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
Correct answer: D
Rationale: When a nurse observes peristomal skin irritation while changing a client's colostomy pouch, it is crucial to ensure that the pouch is slightly larger (0.32 cm or 1/8 inch) than the stoma. This extra space helps prevent the pouch from rubbing against the stoma and causing further irritation. Option A is correct because colostomy pouches should be changed based on individual needs, not necessarily every 24 hours. Option B is incorrect because applying the pouch only when the skin barrier is completely dry ensures better adhesion. Option C is incorrect as patting the peristomal skin dry after cleaning is more gentle and less likely to cause irritation compared to rubbing.
2. Which of the following behaviors is influenced by cultural expectations?
- A. talking openly about the details of the illness
- B. deciding whether to 'feed a cold' or 'starve a fever'
- C. taking herbal supplements to boost the immune system
- D. all of the above
Correct answer: D
Rationale: Cultural expectations can influence all the listed behaviors. Talking openly about the details of an illness may be culturally acceptable or taboo. The decision to 'feed a cold' or 'starve a fever' is often influenced by cultural beliefs and practices. Additionally, the use of herbal supplements to boost the immune system can also be shaped by cultural norms and traditions. Therefore, all the behaviors listed can be influenced by cultural expectations, making option D the correct answer. Choices A, B, and C are incorrect because cultural expectations can impact each of these behaviors.
3. What is one function of water in the human body?
- A. Water provides calories for energy.
- B. Water helps transport nutrients and waste products.
- C. Water acts as a solvent for many biological reactions.
- D. Water maintains body temperature.
Correct answer: B
Rationale: The correct answer is B: Water helps transport nutrients and waste products. Water plays a crucial role in the body by aiding in the transportation of essential nutrients to cells and removing waste products. While water is essential for various metabolic processes, it does not provide calories for energy (choice A). Although water can act as a solvent for biological reactions (choice C), its primary function is not as a solvent. Additionally, while water does help in regulating body temperature to some extent, its main role is not to maintain body temperature (choice D).
4. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?
- A. Position the client 6.1 m (20 ft) away from the Snellen chart
- B. Instruct the client to follow a finger through the six cardinal positions of gaze
- C. Ask the client to cover their right eye during assessment of the left eye
- D. Hold a finger 46 cm (18 inches) away from the client's eye
Correct answer: B
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.
5. A client with diabetes mellitus is receiving insulin glargine (Lantus). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia
- B. Hyperkalemia
- C. Hypertension
- D. Hypercalcemia
Correct answer: A
Rationale: Insulin glargine is a long-acting insulin used to control blood sugar levels in diabetes. The nurse should monitor the client for hypoglycemia, which is a potential side effect of insulin therapy. Hypoglycemia occurs when blood sugar levels drop too low, leading to symptoms such as shakiness, dizziness, sweating, confusion, and in severe cases, loss of consciousness. Hyperkalemia (choice B) is an elevated potassium level, not typically associated with insulin glargine. Hypertension (choice C) is high blood pressure, which is not a common side effect of insulin glargine. Hypercalcemia (choice D) is an elevated calcium level and is not related to the use of insulin glargine.