HESI LPN
HESI Fundamentals Exam
1. A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.)
- A. 0.3 mL
- B. 0.25 mL
- C. 0.4 mL
- D. 0.5 mL
Correct answer: A
Rationale: To calculate the mL to administer, use the formula: Dose required (mg) ÷ Stock concentration (mg/mL) = Volume to administer (mL). In this case, 10 mg ÷ 40 mg/mL = 0.25 mL. However, when rounding to the nearest tenth, the answer should be 0.3 mL. Therefore, the nurse should administer 0.3 mL. Choice A is the correct answer. Choice B (0.25 mL) is the result obtained before rounding. Choice C (0.4 mL) and Choice D (0.5 mL) are incorrect calculations.
2. While measuring a client’s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?
- A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
- B. Measure the blood pressure
- C. Perform an ECG
- D. Recheck the heart rate after 5 minutes
Correct answer: A
Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.
3. How should a healthcare professional manage a child with a newly inserted central venous catheter?
- A. Monitor for signs of infection
- B. Restrict all physical activity
- C. Administer routine antibiotics
- D. Increase fluid intake only
Correct answer: A
Rationale: Monitoring for signs of infection is crucial in managing a central venous catheter to prevent complications. This involves observing for redness, swelling, warmth, or drainage at the catheter site, as these can indicate an infection. Restricting physical activity unnecessarily (choice B) can hinder the child's recovery and quality of life. Administering routine antibiotics (choice C) without a confirmed infection can lead to antibiotic resistance and unnecessary side effects. Increasing fluid intake only (choice D) is not the primary intervention for managing a central venous catheter.
4. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?
- A. Sublimation.
- B. Identification.
- C. Introjection.
- D. Repression.
Correct answer: B
Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.
5. A client with type 2 diabetes mellitus is prescribed exenatide. The nurse should monitor for which potential adverse effect?
- A. Nausea
- B. Hypoglycemia
- C. Hyperglycemia
- D. Pancreatitis
Correct answer: A
Rationale: Exenatide, a medication commonly used in type 2 diabetes, is known to cause gastrointestinal side effects, such as nausea. Monitoring for nausea is essential as it can lead to decreased appetite and potential weight loss, affecting the nutritional status of the client. While hypoglycemia and hyperglycemia are important to monitor in diabetes management, they are not typically associated with exenatide use. Pancreatitis is a rare but serious adverse effect of exenatide, which requires immediate medical attention if suspected.