HESI LPN
HESI Fundamentals Exam Test Bank
1. A healthcare professional is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the healthcare professional expect?
- A. Decreased calcium
- B. Elevated potassium
- C. Increased sodium
- D. Low hemoglobin
Correct answer: A
Rationale: A positive Chvostek's sign is a clinical indication of low calcium levels, known as hypocalcemia. This sign is elicited by tapping the facial nerve anterior to the ear, resulting in facial muscle twitching. The correct laboratory finding associated with a positive Chvostek's sign is decreased calcium. Elevated potassium (Choice B) is not typically associated with Chvostek's sign but can be seen in conditions like renal failure. Increased sodium (Choice C) is not directly related to Chvostek's sign and is more commonly associated with hypernatremia. Low hemoglobin (Choice D) is not the expected laboratory finding in a client with a positive Chvostek's sign; instead, it suggests anemia, which is unrelated to this clinical manifestation.
2. A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. People in middle adulthood often find satisfaction in nurturing and guiding young people.
- B. It's normal to feel this way; it will pass.
- C. You should focus on finding new activities to fill your time.
- D. Your children will always need you in some way.
Correct answer: A
Rationale: The correct response is A. Middle adulthood is a stage where individuals often experience generativity, finding fulfillment in guiding and nurturing others. By acknowledging this aspect, the nurse can help the client explore opportunities to engage in activities that provide a sense of purpose and satisfaction. Choice A validates the client's feelings and offers a constructive way to address them. Choices B, C, and D do not address the client's emotional need for purpose and may not encourage the client to seek meaningful ways to address their feelings of uselessness.
3. When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
- A. The area around the infusion site feels warm to the touch.
- B. The infusion site is swollen and cool to the touch.
- C. The infusion line does not flush properly.
- D. There is no blood return in the infusion line.
Correct answer: A
Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.
4. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?
- A. “I believe in this case you should make an exception and accept the blood transfusion.â€
- B. “I know your family would approve of your decision to have a blood transfusion.â€
- C. “Why does your religion mandate that you cannot receive any blood transfusions?â€
- D. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.â€
Correct answer: D
Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.
5. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?
- A. Calf swelling
- B. Elevated blood pressure
- C. Decreased urine output
- D. Generalized rash
Correct answer: A
Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.
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