HESI LPN
HESI Fundamentals Test Bank
1. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?
- A. Perform deep palpation at the end of the admission assessment
- B. Auscultate the client’s abdomen before palpation
- C. Begin palpation of the abdomen at the site of pain
- D. Assess the client’s bowel sounds using the bell of the stethoscope
Correct answer: B
Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.
2. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?
- A. The client should bottle feed and pump her breast for 3 days following immunization
- B. The vaccine is given to produce maternal antibodies before lactation occurs
- C. The infant will receive immunization through the mother's breast milk
- D. The client should not get pregnant for 3 months after immunization
Correct answer: D
Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.
3. A child with a diagnosis of nephrotic syndrome is being discharged. What dietary instructions should the nurse provide?
- A. Encourage a high-protein diet
- B. Avoid foods high in salt
- C. Encourage a low-sodium diet
- D. Encourage a low-protein diet
Correct answer: B
Rationale: For a child with nephrotic syndrome, it is important to avoid foods high in salt. This instruction helps manage symptoms and prevent complications associated with the condition. High salt intake can lead to fluid retention and worsen edema, which are common issues in nephrotic syndrome. Encouraging a low-sodium diet is crucial to maintaining fluid balance and reducing strain on the kidneys. Choices A, C, and D are incorrect because a high-protein diet can further stress the kidneys, while a low-protein diet may not be necessary unless specifically advised by the healthcare provider. Encouraging a low-sodium diet is more appropriate for managing nephrotic syndrome.
4. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, increasing the risk of infections. Detecting and managing infections promptly is crucial to prevent complications and improve outcomes. Providing nutritional support is important, but infection prevention takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of bleeding is relevant in leukemia due to decreased platelet count, but infection surveillance is more critical. Monitoring for signs of pain is essential, but addressing infections promptly is the priority to prevent further deterioration in the child's condition.
5. A client with diabetes mellitus type 2 is prescribed sitagliptin. The nurse should monitor for which potential adverse effect?
- A. Pancreatitis
- B. Hypoglycemia
- C. Hyperglycemia
- D. Nausea
Correct answer: A
Rationale: Corrected Rationale: Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor used in type 2 diabetes, has been associated with rare cases of pancreatitis. Therefore, the nurse should monitor for signs and symptoms of pancreatitis such as severe abdominal pain, nausea, and vomiting. While hypoglycemia is a potential adverse effect of some diabetes medications, it is less common with sitagliptin. Hyperglycemia is the condition being treated and is not an expected adverse effect of sitagliptin.