HESI LPN
Fundamentals of Nursing HESI
1. During a patient assessment, which principle should be a priority?
- A. Foot care is always important.
- B. Daily bathing is always important.
- C. Hygiene needs are always important.
- D. Critical thinking is always important.
Correct answer: D
Rationale: During a patient assessment, critical thinking is a priority because a patient's condition can change rapidly, necessitating continuous critical thinking and adaptation of nursing interventions. While foot care, daily bathing, and hygiene needs are important components of patient care, they may not always take precedence over critical thinking, which guides the nurse in making timely and appropriate decisions based on the patient's current condition and needs. Therefore, critical thinking stands out as the most crucial principle during patient assessments.
2. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicates a potential hazard for this test?
- A. Reflex incontinence
- B. Allergic to shellfish
- C. Claustrophobia
- D. Hypertension
Correct answer: B
Rationale: The correct answer is B, 'Allergic to shellfish.' An allergy to shellfish can indicate a sensitivity to iodine, which is used in the contrast dye for an IVP, posing a risk of an allergic reaction. Reflex incontinence (Choice A) is not directly related to the potential hazard of an IVP. Claustrophobia (Choice C) and hypertension (Choice D) are also not significant factors that indicate a potential hazard for an IVP.
3. A client with diabetes mellitus reports feeling anxious, shaky, and weak. These findings are manifestations of which of the following complications?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Ketoacidosis
- D. Dawn phenomenon
Correct answer: B
Rationale: The correct answer is B, Hypoglycemia. In diabetes mellitus, hypoglycemia can lead to symptoms such as anxiety, shakiness, and weakness due to low blood sugar levels. Hyperglycemia (choice A) is high blood sugar levels and typically presents with symptoms like increased thirst and frequent urination. Ketoacidosis (choice C) is a serious complication of diabetes characterized by high levels of ketones in the blood, leading to symptoms such as fruity breath and rapid breathing. The Dawn phenomenon (choice D) refers to an abnormal early-morning increase in blood sugar levels without an associated hypoglycemia during the night.
4. A healthcare professional is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The healthcare professional should set the pump to deliver how many mL/hr?
- A. 107 mL/hr
- B. 75 mL/hr
- C. 90 mL/hr
- D. 60 mL/hr
Correct answer: A
Rationale: To calculate the mL/hr rate for the infusion, divide the total volume (750 mL) by the total time (7 hours). 750 mL ÷ 7 hours = 107 mL/hr. This means that the pump should be set to deliver approximately 107 mL/hr. Choice B (75 mL/hr) is incorrect because it does not reflect the correct calculation. Choice C (90 mL/hr) is incorrect as it does not align with the accurate calculation. Choice D (60 mL/hr) is incorrect as it does not match the correct mL/hr rate obtained through the calculation.
5. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
- A. Liver damage
- B. Renal failure
- C. Gastric bleeding
- D. Heart attack
Correct answer: A
Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.
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