HESI LPN
HESI Fundamentals Test Bank
1. A healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)
- A. Develop an acceptance of diminished strength and increased dependence on others.
- B. Spend time focusing on improving job performance.
- C. Welcome opportunities to be creative and productive.
- D. Commit to finding friendship and companionship.
Correct answer: A
Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.
2. During an integumentary assessment for a group of clients, a healthcare professional notes various skin findings. Which of the following findings should the professional recognize as requiring immediate intervention?
- A. Pallor
- B. Cyanosis
- C. Jaundice
- D. Erythema
Correct answer: B
Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.
3. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?
- A. Check IV tubing for obstruction
- B. Increase the flow rate
- C. Change the IV site
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.
4. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glascow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glascow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.
5. If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?
- A. “I will get the caller off the phone as soon as possible so I can alert the staff.”
- B. “I will begin evacuating clients using the elevators.”
- C. “I will not ask any questions and just let the caller talk.”
- D. “I will listen for background noises.”
Correct answer: D
Rationale: The correct answer is D: “I will listen for background noises.” Listening for background noises can provide useful information about the bomb’s location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.
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