HESI LPN
HESI Fundamentals Test Bank
1. A client with cardiovascular disease is being taught by a nurse how to reduce sodium and cholesterol intake. The nurse understands that the most significant factor in planning dietary changes for this client is:
- A. Client’s financial resources
- B. Involvement of the client in planning the change
- C. Availability of low-sodium foods
- D. Frequency of dietary counseling sessions
Correct answer: B
Rationale: The most significant factor in planning dietary changes for a client with cardiovascular disease is the involvement of the client in planning the change. By involving the client in the planning process, the nurse ensures that the client takes ownership of their health and is more likely to adhere to and succeed in modifying dietary habits. This empowerment and engagement enhance the client's motivation and commitment to making sustainable changes. Financial resources, availability of low-sodium foods, and frequency of dietary counseling sessions are important considerations but are not as crucial as the client's active involvement in the planning process.
2. When planning care for a newly admitted elderly client who is severely dehydrated, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report hourly outputs of less than 30 ml/hr
- C. Monitor client's ability to move in the bed
- D. Check skin turgor every 4 hours
Correct answer: B
Rationale: The correct answer is B. Assigning the UAP to report hourly outputs of less than 30 ml/hr is appropriate as it falls within their scope of practice and does not involve making clinical assessments or decisions. Choices A, C, and D involve tasks that require a higher level of clinical judgment and training. Choice A requires assessing mucous membranes, which is beyond the UAP's scope. Choice C involves assessing movement ability, which requires more specialized training. Choice D involves assessing skin turgor, which also requires a higher level of clinical judgment.
3. What assessment is the priority focus for a client with major depression?
- A. Mood and affect.
- B. Suicidal ideation.
- C. Nutritional status.
- D. Fluid and electrolyte balance.
Correct answer: B
Rationale: The correct answer is B: Suicidal ideation. When dealing with a client diagnosed with major depression, assessing for suicidal ideation is of utmost importance. Individuals with major depression have an increased risk of suicide; hence, evaluating their risk for self-harm is crucial. Mood and affect, while important, come secondary to ensuring the safety of the client. Nutritional status and fluid and electrolyte balance are essential components of care but are not the priority when dealing with a client with major depression.
4. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?
- A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
- B. To prevent infection, the dressing should be kept dry to avoid excess moisture
- C. The skin incision should be kept moist to promote healing and prevent dryness
- D. The incision should be protected from fecal contamination by an intact dressing
Correct answer: D
Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
5. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.