HESI LPN
Fundamentals of Nursing HESI
1. A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
- A. Avoid measuring the client’s temperature rectally.
- B. Count the client’s radial pulse for 30 seconds and multiply it by 2.
- C. Count the client’s respirations discreetly.
- D. Allow the client to rest for 5 minutes before measuring their BP.
Correct answer: A
Rationale: The correct answer is to avoid measuring the client’s temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.
2. Which level of care serves as a referral center for primary health facilities?
- A. Secondary level health care
- B. Primary health care
- C. Tertiary level care
- D. Intermediate level care
Correct answer: A
Rationale: Secondary level health care is the correct answer as it serves as a referral center for primary health facilities. Primary health care refers to basic health services provided in the community setting. Tertiary level care involves specialized services like hospitals with advanced medical equipment and expertise. Intermediate level care is not a standard term in the hierarchy of health care services.
3. A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?
- A. Did you try to resist or fight back when you felt uncomfortable?
- B. He hurt you? Can you elaborate on what happened?
- C. It is okay to cry, but first, let's address your injuries and the situation.
- D. Yes, I can see. Tell me more about what you remember.
Correct answer: D
Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.
4. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?
- A. Determine serum potassium level
- B. Calculate the client’s daily fluid intake
- C. Assess client for signs of vertigo
- D. Review the client’s pulse oximetry reading
Correct answer: A
Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.
5. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?
- A. Check the placement of the NG tube
- B. Flush the tube with saline
- C. Position the client in a semi-Fowler's position
- D. Administer the medication slowly
Correct answer: A
Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.