HESI LPN
Practice HESI Fundamentals Exam
1. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?
- A. Wearing gloves during the procedure
- B. Using a sterile solution
- C. Irrigating from the inner to the outer canthus
- D. Positioning the client's head properly
Correct answer: A
Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.
2. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?
- A. Begin 0.9% saline solution intravenously as prescribed
- B. Administer regular insulin intravenously as prescribed
- C. Place child on a cardiac monitor
- D. Place child on a pulse oximetry monitor
Correct answer: A
Rationale: Initiating intravenous saline solution is the initial priority in managing diabetic ketoacidosis to address dehydration and electrolyte imbalances. Administering insulin without addressing dehydration first can lead to potential complications. While monitoring cardiac status and oxygen saturation are important, addressing the fluid and electrolyte imbalances takes precedence in the management of DKA.
3. What is a common symptom of congenital heart disease in infants?
- A. Excessive weight gain
- B. Difficulty breathing
- C. High blood pressure
- D. Increased appetite
Correct answer: B
Rationale: Difficulty breathing is a common symptom of congenital heart disease in infants. Infants with congenital heart disease may experience difficulty breathing due to impaired cardiac function, which affects the heart's ability to pump blood effectively. This symptom is often due to issues like heart failure or fluid accumulation in the lungs. Excessive weight gain (Choice A) is not typically associated with congenital heart disease in infants. High blood pressure (Choice C) is less common in infants with congenital heart disease compared to adults. Increased appetite (Choice D) is not a typical symptom of congenital heart disease in infants.
4. A client with hypertension is prescribed amlodipine. The nurse should monitor for which potential adverse effect?
- A. Peripheral edema
- B. Bradycardia
- C. Hypertension
- D. Increased appetite
Correct answer: A
Rationale: Corrected Rationale: Amlodipine is known to cause peripheral edema as a potential adverse effect due to its vasodilatory properties. This can lead to fluid accumulation in the extremities. Monitoring for peripheral edema in patients taking amlodipine is crucial to identify and manage this side effect promptly. Choices B, C, and D are incorrect because amlodipine is not associated with causing bradycardia, hypertension (as the patient already has hypertension), or increased appetite as adverse effects.
5. At 31 weeks gestation, a client with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide?
- A. Assessment for congenital anomalies
- B. Recalculation of gestational age
- C. Evaluation of fetal growth
- D. Determination of fetal presentation
Correct answer: C
Rationale: The correct answer is C: 'Evaluation of fetal growth.' A fundal height measurement smaller than expected may indicate intrauterine growth restriction (IUGR), requiring serial ultrasounds to monitor fetal growth. Assessing for congenital anomalies (choice A) is usually done through detailed anatomy scans earlier in pregnancy. Recalculating gestational age (choice B) is typically unnecessary at this stage unless there are concerns about accuracy. Determining fetal presentation (choice D) is usually done closer to term to plan for the mode of delivery.