HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct answer: C
Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.
2. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?
- A. Avoid standing up too quickly.
- B. Increase fluid intake to stay hydrated.
- C. Eat more salt to help retain fluids.
- D. Wear compression stockings during the day.
Correct answer: A
Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.
3. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer?
- A. 0.5 ml
- B. 1 ml
- C. 1.5 ml
- D. 2 ml
Correct answer: A
Rationale: To administer 4 mg of morphine, as prescribed, the LPN/LVN needs to calculate the correct volume based on the concentration provided (8 mg per ml). Since the desired dose is 4 mg, half of 8 mg (0.5 ml) is required to administer the correct amount. Therefore, the correct answer is 0.5 ml. Choices B, C, and D are incorrect as they would either underdose or overdose the patient.
4. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
- A. Assessment
- B. Plan of care
- C. Client history
- D. Medication list
Correct answer: A
Rationale: The correct answer is A: Assessment. When admitting a client, the nurse should document assessment data first. This information is crucial as it provides a baseline for planning care and treatment. By documenting the assessment initially, the nurse can accurately identify the client's needs and prioritize care. Choice B, Plan of care, would be developed based on the assessment findings, so it should come after the initial assessment. Choices C and D, Client history and Medication list, are important but would typically be documented after the assessment to ensure that the most current and relevant information is captured in the client's record.
5. Based on the documentation in the medical record, which action should the nurse implement next?
- A. Administer the rubella vaccine subcutaneously
- B. Observe the mother breastfeeding her infant
- C. Call the nursery for the infant's blood type result
- D. Administer Vicodin one tablet for pain
Correct answer: B
Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.