HESI LPN
HESI Fundamentals Test Bank
1. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching?
- A. “I should keep feeding my son whole milk until he is 3 years old.”
- B. “It’s okay for me to give my son a cup of apple juice with each meal.”
- C. “I’ll give my son about 2 tablespoons of each food at mealtimes.”
- D. “My son loves popcorn, and I know it is better for him than sweets.”
Correct answer: C
Rationale: The correct answer is C. Offering a variety of foods in small portions is appropriate for a 2-year-old toddler as it helps provide balanced nutrition and allows the child to explore different tastes and textures. Choice A is incorrect because whole milk is recommended up to 2 years old, not until 3 years old. Choice B is incorrect as excessive juice intake can lead to excessive sugar consumption and is not recommended. Choice D is incorrect as popcorn may pose a choking hazard for toddlers and is not a suitable alternative to sweets.
2. What intervention should the PN implement when taking the rectal temperature of an adult client?
- A. Lubricate the tip of the thermometer with a water-based gel.
- B. Gently insert the thermometer 1 inch into the rectum.
- C. Hold the thermometer in place the entire time while taking the temperature.
- D. Place the client in the left lateral position.
Correct answer: C
Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.
3. A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?
- A. The neck extended backward using a rolled towel behind the neck
- B. Prone position using pillows to support both arms outward from the torso
- C. Side-lying position using pillows to support the abdomen and back
- D. The neck forward using pillows under the head and sandbags on both sides
Correct answer: D
Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.
4. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?
- A. Stay with the client and ensure her safety.
- B. Inform the client that she is safe in the hospital.
- C. Document the client's statements in her medical record.
- D. Encourage the client to join a group therapy session.
Correct answer: A
Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.
5. During the admission assessment of a terminally ill male client, he states that he is agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement of the client’s spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client’s choice
Correct answer: B
Rationale: The best nursing action in response to a terminally ill client stating their agnostic beliefs is to document the client's spiritual assessment. By documenting this information, the healthcare team can ensure that the client's beliefs are acknowledged and respected in their care plan. Providing information about the chapel's hours or inviting the client to a healing service may not align with the client's beliefs and preferences. Offering to contact a spiritual advisor of the client's choice may not be necessary if the client has clearly stated their agnostic beliefs, as they may not wish to engage in spiritual counseling.