HESI LPN
HESI Fundamentals Test Bank
1. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
- A. Establish goals that are measurable and realistic.
- B. Set goals that are a little beyond the capabilities of the patient.
- C. Use the nurse's own judgment and not be swayed by family desires.
- D. Explain that without taking alignment risks, there can be no progress.
Correct answer: A
Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.
2. A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and initiate oxygen therapy. En route to the hospital, you should be most alert for:
- A. vomiting
- B. seizures
- C. combativeness
- D. respiratory distress
Correct answer: B
Rationale: In a pediatric patient presenting with altered mental status, high fever, and a generalized rash, seizures are a significant concern. Febrile seizures can occur in children with high fevers and may lead to further complications. It is crucial to monitor for seizures and be prepared to manage them promptly. Vomiting, combativeness, and respiratory distress are also important considerations in pediatric patients; however, given the clinical presentation described, seizures take priority as they are a common complication in this scenario.
3. A client with a urinary tract infection is prescribed antibiotics. What should the nurse inform the client about antibiotic therapy?
- A. It may interfere with oral contraceptive effectiveness
- B. It can cause drowsiness
- C. It should be taken with meals
- D. Completing the full course is crucial
Correct answer: D
Rationale: Completing the full course of antibiotics is crucial to fully eradicate the infection and prevent the development of antibiotic resistance. Informing the client about the importance of finishing the prescribed course helps in ensuring the effectiveness of the treatment and reduces the risk of recurrence. Choice A is incorrect because antibiotics do not generally interfere with oral contraceptive effectiveness. Choice B is incorrect because drowsiness is not a common side effect of antibiotics. Choice C is incorrect because while some antibiotics may need to be taken with meals, it is not a universal rule for all antibiotics.
4. The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?
- A. Stand the client to void and run tap water within hearing distance before catheterizing
- B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
- C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
- D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon
Correct answer: D
Rationale: Prompt and appropriate management of urinary retention prevents complications like infection and bladder damage.
5. Nurse Andy has finished teaching a client with diabetes mellitus how to administer insulin. He evaluates the learning has occurred when the client makes which statement?
- A. I should check my blood sugar immediately prior to the administration.
- B. I should provide direct pressure over the site following the injection.
- C. I should use the abdominal area only for insulin injections.
- D. I should only use a calibrated insulin syringe for the injections.
Correct answer: D
Rationale: The correct answer is D because using a calibrated insulin syringe is crucial for accurate dosing when administering insulin. Choice A is incorrect because checking blood sugar before administration is essential but not the specific evaluation of learning in this context. Choice B is incorrect as applying direct pressure over the injection site is not a key indicator of learning about insulin administration. Choice C is incorrect as insulin injections can also be administered in other sites like the thigh or arm; it is not limited to the abdominal area.