HESI LPN
Practice HESI Fundamentals Exam
1. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?
- A. Albumin level of 3 g/dL
- B. Hemoglobin level of 12 g/dL
- C. WBC count of 6,000/mm³
- D. Blood glucose level of 100 mg/dL
Correct answer: A
Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.
2. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
- A. Evacuate the client
- B. Attempt to extinguish the fire
- C. Call the fire department
- D. Close the door to contain the fire
Correct answer: A
Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.
3. A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- A. Discard the first voiding.
- B. Keep the urine in a single container on ice.
- C. Include the last voiding in the collection.
- D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct answer: A
Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.
4. What is an essential nursing action before administering a blood transfusion?
- A. Checking the patient’s blood pressure
- B. Verifying the blood type and patient identity with another nurse
- C. Flushing the IV line with saline
- D. Administering pre-transfusion medications
Correct answer: B
Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.
5. What is a key intervention for a child with a new diagnosis of type 1 diabetes?
- A. Insulin administration
- B. Increased dietary fat intake
- C. Restricted fluid intake
- D. Routine physical examinations only
Correct answer: A
Rationale: The correct answer is A: Insulin administration. When a child is diagnosed with type 1 diabetes, insulin administration is a crucial intervention. Insulin helps regulate blood glucose levels by enabling cells to take in glucose from the bloodstream. Without sufficient insulin, blood glucose levels can become dangerously high, leading to various complications. Increased dietary fat intake (choice B) is not a recommended intervention for type 1 diabetes management, as it can contribute to weight gain and other health issues. Restricted fluid intake (choice C) is also not appropriate, as adequate hydration is essential for overall health. Routine physical examinations (choice D) are important but are not the primary intervention needed to manage type 1 diabetes.