HESI LPN
Practice HESI Fundamentals Exam
1. A client who requires maximal support is being taught how to use a two-wheeled walker by a nurse. Which of the following actions by the client indicates an understanding of the teaching?
- A. The client moves the walker ahead 25.4 cm with each step
- B. The client picks up the walker with each step
- C. The client stands with elbows slightly bent while holding the walker
- D. The client stoops slightly forward when moving the walker
Correct answer: C
Rationale: The correct answer is C. When using a two-wheeled walker, the client should stand with elbows slightly bent to maintain balance and stability. This position helps distribute weight effectively and promotes proper use of the walker. Choices A, B, and D are incorrect. Choice A does not demonstrate proper posture while using the walker. Choice B of picking up the walker with each step is not the correct technique and can lead to instability. Choice D of stooping slightly forward is also incorrect as it can affect balance and posture negatively.
2. A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Tuberculosis
Correct answer: D
Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.
3. A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?
- A. Spaghetti and meatballs
- B. Chicken salad sandwich
- C. Steak and potatoes
- D. Hamburger and fries
Correct answer: B
Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.
4. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct answer: D
Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.
5. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
- A. Remove the restraints from the client's wrists
- B. Review the chart for nonrestraint alternatives for agitation
- C. Speak with the AP about the incident
- D. Inform the unit manager of the incident
Correct answer: A
Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.