HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the healthcare professional adjust the manual IV infusion to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 83 gtt/min
- B. 125 gtt/min
- C. 100 gtt/min
- D. 75 gtt/min
Correct answer: C
Rationale: To administer 250 mL over 30 min with a drop factor of 10 gtt/mL, the healthcare professional should adjust the IV infusion to deliver 100 gtt/min. The correct calculation is: (250 mL รท 30 min) x 10 gtt/mL = 100 gtt/min. This rate ensures the proper administration of the IV solution within the specified time frame. Choices A, B, and D are incorrect as they do not align with the accurate calculation based on the provided data.
2. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?
- A. Reassure the client that he will become accustomed to the stoma's appearance in time.
- B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
- C. Offer to contact a member of the local ostomy support group to help him with his concerns.
- D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Correct answer: B
Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.
3. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?
- A. Place the client on seizure precautions and monitor her frequently.
- B. Take the client's vital signs and notify the physician immediately.
- C. Describe the symptoms to the charge nurse and document them in the client's record.
- D. No action is required at this time as these are known side effects of her medications.
Correct answer: B
Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.
4. A client with a history of atrial fibrillation is prescribed digoxin. The nurse should monitor for which potential side effect?
- A. Bradycardia
- B. Tachycardia
- C. Headache
- D. Hyperglycemia
Correct answer: A
Rationale: The correct answer is A: Bradycardia. Digoxin can lead to bradycardia due to its effect on slowing down the heart rate, which can be dangerous in a client with atrial fibrillation. Monitoring the client's heart rate is essential to detect and manage this potential side effect. Choices B, C, and D are incorrect because digoxin is not known to cause tachycardia, headache, or hyperglycemia as common side effects.
5. An additional defect is associated with exstrophy of the bladder. For what anomaly should the nurse assess the infant?
- A. Imperforate anus
- B. Absence of one kidney
- C. Congenital heart disease
- D. Pubic bone malformation
Correct answer: D
Rationale: The correct answer is D, pubic bone malformation. Exstrophy of the bladder is commonly associated with pubic bone malformation because the condition involves a defect in the pelvic region. Choices A, B, and C are incorrect. Imperforate anus, absence of one kidney, and congenital heart disease are not typically associated with exstrophy of the bladder.