HESI LPN
HESI Fundamentals 2023 Quizlet
1. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
2. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.
- A. Breast screening for older women
- B. Rehabilitation services for stroke victims
- C. Blood pressure assessments
- D. Antepartum nutritional counseling
Correct answer: A
Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.
3. When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
- A. Lactate
- B. Glucose
- C. Hemoglobin
- D. Creatinine
Correct answer: B
Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.
4. What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?
- A. Encourage the client to use an incentive spirometer regularly.
- B. Assist the client in ambulating as soon as possible.
- C. Position the client in high Fowler's position.
- D. Encourage the client to cough and deep breathe regularly.
Correct answer: A
Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.
5. While waiting for the administration of air pressure to reduce the intussusception, the boy passes a normal brown stool. Which nursing action is the most appropriate for the nurse to take?
- A. notify the practitioner
- B. measure abdominal girth
- C. auscultate for bowel sounds
- D. take vital signs, including blood pressure
Correct answer: A
Rationale: The correct answer is to notify the practitioner. The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. It is crucial to inform the practitioner immediately so that they can reassess the situation and determine the next steps, which may include adjusting the planned intervention. Measuring abdominal girth (choice B) may be important in assessing for abdominal distension but is not the most immediate action required in this scenario. Auscultating for bowel sounds (choice C) is a routine nursing assessment but does not take precedence over notifying the practitioner in this critical situation. Taking vital signs, including blood pressure (choice D), is also important but notifying the practitioner is more urgent to address the unexpected change in the patient's condition.