HESI LPN
HESI Fundamental Practice Exam
1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Place the client in a side-lying position
- B. Instill 15 mL of irrigation fluid into the catheter with each flush
- C. Subtract the amount of irrigant used from the client's urine output
- D. Perform the irrigation using a 20 mL syringe
Correct answer: C
Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
2. What foods are appropriate for a 30-month-old toddler on a regular diet?
- A. Hamburger with bun and grapes
- B. Chicken fingers and french fries
- C. Hot dog with bun and potato chips
- D. Macaroni and cheese and Cheerios
Correct answer: D
Rationale: Macaroni and cheese and Cheerios are appropriate choices for a 30-month-old toddler on a regular diet. These foods are easy to chew, digest, and are generally well-liked by toddlers. Option A, a hamburger with bun and grapes, may be difficult for a toddler to handle due to the size of the hamburger and grapes pose a choking hazard. Option B, chicken fingers and french fries, may be too greasy and processed for a toddler's developing digestive system. Option C, hot dog with bun and potato chips, is also not ideal as hot dogs can be a choking hazard and potato chips are high in salt and may not provide adequate nutrition.
3. A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?
- A. Assess the client’s need for pain medication
- B. Document the impending signs of death
- C. Inform the nurse manager of the client’s status
- D. Communicate the client’s status to the chaplain
Correct answer: A
Rationale: Assessing the client’s need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.
4. A client who is malnourished expresses concern about losing their loose wedding ring. What is the most appropriate action for the nurse to take?
- A. I can pin it to your hospital gown to prevent it from falling off.
- B. I will place it in your drawer to keep it safe.
- C. I will hold onto it until a family member can retrieve it.
- D. I can put it in a locked storage unit for you.
Correct answer: D
Rationale: The most appropriate action for the nurse to take is to put the client's wedding ring in a locked storage unit for safekeeping. This ensures that the ring is secure and minimizes the risk of loss or damage. Choices A, B, and C do not provide the same level of security and protection as placing the ring in a locked storage unit. Pinning it to the hospital gown (Choice A) may not be secure and could still lead to loss. Placing it in the client's drawer (Choice B) may not guarantee its safety. Holding onto it until a family member retrieves it (Choice C) leaves the ring vulnerable to misplacement or theft.
5. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
- A. A client who has a broken femur and reports hip pain.
- B. A client who has incisional pain 72 hours following pacemaker insertion.
- C. A client who has food poisoning and reports abdominal cramping.
- D. A client who has episodic back pain following a fall 2 years ago.
Correct answer: D
Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.