HESI LPN
Fundamentals of Nursing HESI
1. A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?
- A. Moves the patient's arm in a full circle.
- B. Moves the patient's arm across the body as far as possible.
- C. Moves the patient's arm behind the body, keeping the elbow straight.
- D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.
Correct answer: D
Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.
2. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?
- A. Erythema on pressure points
- B. Lower-extremity pulse strength of 2+
- C. Fluid intake of 3,000 mL per day
- D. A bowel movement every other day
Correct answer: A
Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.
3. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?
- A. Pull down and out at the back of the upper denture to remove.
- B. Brush the dentures with a toothbrush and denture cleaner.
- C. Rinse the dentures with hot water after cleaning them.
- D. Place the dentures in a clean, dry storage container after cleaning them.
Correct answer: B
Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.
4. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?
- A. Ask the client what precipitates the pain.
- B. Question the client about the location of the pain.
- C. Offer the client a pain scale to measure their pain.
- D. Use open-ended questions to identify the client’s pain sensations.
Correct answer: C
Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.
5. A client has a sodium level of 125. What findings should the nurse expect?
- A. Abdominal cramping
- B. Elevated blood pressure
- C. Decreased heart rate
- D. Increased thirst
Correct answer: A
Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.
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