HESI LPN
HESI Practice Test for Fundamentals
1. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?
- A. Apply the cuff above the client's antecubital fossa.
- B. Use a cuff with a width that is about 60% of the client's arm circumference.
- C. Have the client sit with their arm resting at the level of their heart.
- D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.
Correct answer: A
Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.
2. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?
- A. Lorazepam (Ativan)
- B. Famotidine (Pepcid)
- C. Thiamine (Vitamin B1)
- D. Atenolol (Tenormin)
Correct answer: C
Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.
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 with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?
- A. Perform a physical assessment
- B. Review the client's medication list
- C. Instruct the client to elevate the legs
- D. Obtain a detailed dietary history
Correct answer: A
Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.
5. A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Administer the medication with the needle at a 30-degree angle.
- D. Administer the medication with the needle at a 15-degree angle.
Correct answer: B
Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.