HESI LPN
HESI Fundamentals Exam
1. A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?
- A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
- B. Recheck the pulse at the same site after 5 minutes.
- C. Measure the client’s blood pressure.
- D. Record the irregularity and continue with other vital signs.
Correct answer: A
Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (Choice B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (Choice C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (Choice D) may overlook a potentially serious cardiac issue that requires immediate attention.
2. A client with diabetes mellitus type 2 is prescribed glipizide. What instruction should the nurse include in the client's teaching plan?
- A. Take this medication with meals.
- B. Avoid alcohol while taking this medication.
- C. Take this medication on an empty stomach.
- D. Report any signs of hypoglycemia to the healthcare provider.
Correct answer: A
Rationale: The correct instruction for a client prescribed glipizide, a sulfonylurea used to lower blood sugar levels, is to take the medication with meals. Taking it with meals helps to minimize the risk of hypoglycemia by ensuring a more balanced effect on blood glucose levels throughout the day. It is important for the client to follow this instruction to maintain stable blood sugar levels and reduce the likelihood of experiencing low blood sugar (hypoglycemia) episodes. Choice B is incorrect because there are no specific contraindications between glipizide and alcohol. Choice C is incorrect as glipizide should not be taken on an empty stomach. Choice D is incorrect as while it is important to report signs of hypoglycemia, the primary focus should be on preventing hypoglycemia by taking the medication with meals.
3. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?
- A. Images indicate the presence of tumors and scars.
- B. The scan clearly outlines structures of the brain.
- C. Results show activity in various portions of the brain.
- D. PET shows biochemical levels of neurotransmitters.
Correct answer: C
Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.
4. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will have a client who is on airborne precautions wear a mask when out of their room.
- B. I will wear an N95 respirator mask for a client who is on droplet precautions.
- C. I will place a client who has compromised immunity in a negative-pressure airflow room.
- D. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
Correct answer: A
Rationale: The correct answer is A. Having a client on airborne precautions wear a mask when out of their room is appropriate to prevent the spread of infection. Choice B is incorrect because the healthcare provider, not the client, wears an N95 respirator mask for a client on droplet precautions. Choice C is incorrect because negative-pressure airflow rooms are used for clients with airborne infections, not compromised immunity. Choice D is incorrect because visitors, not clients, should wear a mask when visiting a client on contact precautions.
5. Clients with type 1 diabetes may require which of the following changes to their daily routine during periods of infection?
- A. No change
- B. Less insulin
- C. More insulin
- D. Oral antidiabetic agents
Correct answer: C
Rationale: During periods of infection, clients with type 1 diabetes may require more insulin to manage the increased blood glucose levels caused by stress and illness. Insulin needs often rise during infections due to the body's increased resistance to the effects of insulin. Therefore, increasing insulin doses is crucial to maintain blood glucose control. Choices A, B, and D are incorrect. Option A ('No change') is inaccurate because during infections, insulin requirements typically increase. Option B ('Less insulin') is incorrect as the body's increased insulin resistance during infections usually necessitates higher insulin doses. Option D ('Oral antidiabetic agents') is not suitable for type 1 diabetes management as these medications are primarily used for type 2 diabetes.