HESI LPN
HESI Fundamentals Exam
1. A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
- A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
- B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
- C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
- D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.
Correct answer: C
Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.
2. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?
- A. Record usual eating patterns
- B. Evaluate for muscle cramping
- C. Document abdominal girth
- D. Elevate both legs on pillows
Correct answer: B
Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.
3. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct answer: B
Rationale: The correct answer is B: secondary prevention. Secondary prevention involves identifying and addressing issues early to prevent further harm. In this scenario, the nurse is intervening by discussing domestic violence prevention with the client who is showing signs of facial bruising, aiming to prevent further harm even though the client has not disclosed being battered. Choice A (primary prevention) focuses on preventing the onset of a problem before it occurs, like educating about healthy relationships before violence happens. Choice C (tertiary prevention) involves managing and treating the effects of a problem that has already occurred, such as providing counseling to a domestic violence survivor. Choice D (health promotion) aims to enhance well-being and prevent health problems through educational and environmental interventions, which may include aspects of preventing domestic violence, but in this case, the nurse's direct intervention is more about early identification and prevention of harm, aligning it with secondary prevention.
4. A client is preparing to attend a Gamblers Anonymous meeting for the first time. The prototype used by this group is the 12-step program developed by Alcoholics Anonymous. Number in order of priority how the steps would be addressed.
- A. Admitting to oneself and to another human being the exact nature of one's wrongs
- B. Acknowledging that one is entirely ready to have his or her defects of character removed
- C. Admitting that oneself is powerless over gambling and that one's life has become unmanageable
- D. Making an effort to practice the 12-step principles in all affairs, and to carry out this message to other compulsive gamblers
Correct answer: D
Rationale: The correct order of addressing the 12-step program typically begins with admitting powerlessness over the addiction and recognizing the unmanageability of one's life (Choice C). Following this, individuals move towards acknowledging their wrongs and sharing them with others (Choice A), then being ready to work on changing their character defects (Choice B), and finally, integrating the 12-step principles into their daily lives and helping others (Choice D). Choices A, B, and C are important steps in the program but come after admitting powerlessness and unmanageability, which is why Choice D is the correct answer.
5. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?
- A. Provide a protein intake of 1.5 g/kg of body weight per day.
- B. Increase carbohydrate intake to 50% of daily calories.
- C. Administer high-dose vitamin supplements.
- D. Ensure a daily intake of 1000 calories.
Correct answer: A
Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.