HESI LPN
HESI Fundamentals Test Bank
1. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client’s weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
2. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
- A. Airway
- B. Blood pressure
- C. Surgical site
- D. Level of consciousness
Correct answer: A
Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.
3. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?
- A. Remove the client’s stockings at least once during each shift
- B. Roll the top of the client’s stockings down to just below the knee
- C. Seat the client in a chair for 30 minutes prior to applying stockings
- D. Measure the length of the client’s leg from the heel to the gluteal fold
Correct answer: A
Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.
4. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?
- A. Record the coughing incident. No further action is required at this time.
- B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
- C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
- D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct answer: C
Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.
5. What is a long-term complication of cleft lip and palate?
- A. Cognitive impairment
- B. Altered growth and development
- C. Faulty dentition
- D. Physical abilities
Correct answer: C
Rationale: The correct long-term complication of cleft lip and palate is faulty dentition. Individuals with cleft lip and palate may experience dental issues such as missing, extra, or misaligned teeth, which can affect speech and the aesthetic appearance of the mouth. Cognitive impairment, as mentioned in choice A, is not a typical long-term complication associated with cleft lip and palate. While altered growth and development (choice B) can be affected during early stages, it is not a prominent long-term complication. Choice D, physical abilities, is not directly related to the typical long-term complications of cleft lip and palate.