HESI LPN
HESI Fundamentals Exam Test Bank
1. A healthcare professional is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the healthcare professional use to obtain the temperature?
- A. Temporal
- B. Oral
- C. Rectal
- D. Axillary
Correct answer: C
Rationale: In a 2-year-old child with diarrhea and a possible ear infection, rectal temperature measurement is the most accurate reflection of core body temperature. This method provides the most reliable reading, especially in young children, as it closely reflects the core body temperature. Oral temperature may not be accurate due to the child's recent diarrhea, which can affect oral readings. Axillary temperature may not be as accurate as rectal temperature in this case. Temporal temperature measurement, although non-invasive, may not provide the most accurate core body temperature reading, especially in a child with a potential ear infection.
2. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?
- A. Ambulate the client 4 hours after the procedure
- B. Maintain the client on NPO status for 24 hours
- C. Monitor vital signs
- D. Change the dressing every 8 hours
Correct answer: C
Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.
3. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned infants.
- B. Port wine stains are typically associated with other malformations.
- C. Telangiectatic nevi are normal and will disappear as the baby grows.
- D. The child is too young for surgical removal of these at this time.
Correct answer: C
Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.
4. While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?
- A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
- B. Determine the reasons why the client is refusing to use the incentive spirometer
- C. Document the client's refusal to participate in health restorative activities
- D. Administer a pain medication to the client
Correct answer: B
Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.
5. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
- A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
- B. A nurse asks a nurse from another unit to assist with her documentation.
- C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
- D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.
Correct answer: B
Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.
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