HESI LPN
HESI Practice Test for Fundamentals
1. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Assist the client with a partial bed bath
- B. Measure the client's BP after the nurse administers an antihypertensive medication
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct answer: A
Rationale: In this scenario, the nurse should assign the task of assisting the client with a partial bed bath to an assistive personnel (AP). APs are trained to provide basic care tasks like hygiene assistance. Options B, C, and D involve more complex tasks such as measuring BP, using a communication board for speech-impaired clients, and feeding, which require nursing judgment and skills beyond basic care. Therefore, these tasks should be performed by licensed nursing staff who can assess, communicate effectively, and address the specific medical and safety needs of the client.
2. What is an essential part of care for a child with asthma during an acute episode?
- A. Administer a bronchodilator
- B. Provide high doses of steroids
- C. Increase fluid intake
- D. Restrict all physical activity
Correct answer: A
Rationale: Administering a bronchodilator is an essential part of caring for a child with asthma during an acute episode because it helps to open airways and relieve acute asthma symptoms effectively. Providing high doses of steroids (Choice B) is typically done in severe cases or when other treatments fail. Increasing fluid intake (Choice C) can be beneficial to prevent dehydration, but it is not the primary intervention during an acute asthma episode. Restricting all physical activity (Choice D) is not recommended as some physical activity may help improve lung function and overall well-being.
3. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?
- A. Document the finding and continue to monitor.
- B. Apply warm compresses to the stoma.
- C. Notify the healthcare provider immediately.
- D. Encourage the client to ambulate.
Correct answer: C
Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.
4. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?
- A. Changes in mental status
- B. Urine output and color
- C. Blood pressure and heart rate
- D. Skin turgor
Correct answer: A
Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.
5. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Secure the tube to the client's gown.
- C. Check the placement of the tube by auscultation.
- D. Irrigate the tube with normal saline every shift.
Correct answer: A
Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.