a nurse is performing an admission assessment for an older adult client after gathering the assessment data and performing the review of systems which a nurse is performing an admission assessment for an older adult client after gathering the assessment data and performing the review of systems which
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HESI LPN

Practice HESI Fundamentals Exam

1. During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?

Correct answer: A

Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.

2. Which of the following is a common complication of an untreated inguinal hernia in children?

Correct answer: B

Rationale: The correct answer is B: Strangulation of the hernia. Untreated inguinal hernias in children can lead to strangulation, which can result in bowel obstruction and ischemia. This is a serious complication that requires prompt medical attention. Choices A, C, and D are incorrect. Gastroenteritis is a gastrointestinal infection that is not directly related to untreated inguinal hernias. Chronic cough is not typically associated with this condition. Epistaxis refers to nosebleeds, which are not a common complication of untreated inguinal hernias in children.

3. A post-op nurse has an indwelling catheter in place for gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:

Correct answer: A

Rationale: The correct action for the nurse to take when the urine bag has not filled for 2 hours is to check if the tubing is kinked. Kinks in the tubing can obstruct the flow of urine from the catheter, leading to decreased drainage. Increasing the IV fluid rate is not the appropriate initial action in this situation as the primary concern is with the catheter drainage. Checking the catheter insertion site would be secondary to ensuring proper drainage. Contacting the healthcare provider is not necessary as the issue can often be resolved by checking for simple tubing obstructions first.

4. During a client admission, how should the nurse conduct medication reconciliation?

Correct answer: A

Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.

5. A client with severe rheumatoid arthritis is prescribed methotrexate. The nurse should monitor the client for which potential adverse effect?

Correct answer: A

Rationale: The correct answer is A: Bone marrow suppression. Methotrexate, commonly used in rheumatoid arthritis, can lead to bone marrow suppression, reducing the production of blood cells and increasing the risk of infection. Monitoring for signs of anemia, leukopenia, and thrombocytopenia is crucial to detect bone marrow suppression early and prevent complications. Choices B, C, and D are incorrect because while methotrexate can increase the risk of infection, liver toxicity, and kidney issues, the primary concern and most significant adverse effect to monitor for is bone marrow suppression due to its impact on blood cell production.

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HESI Basic

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