HESI LPN
HESI Practice Test for Fundamentals
1. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
- A. Using a cuff that is too small will result in an inaccurately high reading.
- B. Using a cuff that is too large will result in an inaccurately low reading.
- C. The regular size cuff is appropriate for all clients.
- D. You should use a cuff of any size as long as it fits.
Correct answer: A
Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.
2. During an admission assessment on an HIV positive client diagnosed with Pneumocystis carinii pneumonia (PCP), which symptoms should the nurse carefully observe the client for?
- A. Weight loss exceeding 10 percent of baseline body weight
- B. Altered mental status and tachypnea
- C. Creamy white patches in the oral cavity
- D. Normal ABGs with wet lung sounds in all lung fields
Correct answer: B
Rationale: The correct answer is B: Altered mental status and tachypnea. These symptoms are indicative of PCP and severe HIV progression. Weight loss exceeding 10 percent of baseline body weight (choice A) may be seen in HIV/AIDS but is not specific to PCP. Creamy white patches in the oral cavity (choice C) are characteristic of oral thrush, which is more commonly associated with Candida infections in HIV patients. Normal ABGs with wet lung sounds in all lung fields (choice D) would not be expected with PCP, as it typically presents with hypoxemia and diffuse bilateral infiltrates on chest imaging.
3. A 4-year-old child is admitted with a diagnosis of bacterial pneumonia. What is the priority nursing intervention?
- A. Administering antipyretics
- B. Administering antibiotics
- C. Monitoring fluid intake
- D. Providing nutritional support
Correct answer: B
Rationale: The priority nursing intervention in a 4-year-old child admitted with bacterial pneumonia is administering antibiotics. Antibiotics are crucial for treating the infection and preventing potential complications. Administering antipyretics (Choice A) may help reduce fever, but addressing the underlying infection with antibiotics is the priority. Monitoring fluid intake (Choice C) is important for hydration but does not take precedence over administering antibiotics. Providing nutritional support (Choice D) is essential for overall care but is not the immediate priority when managing bacterial pneumonia.
4. A client with a diagnosis of chronic heart failure is prescribed digoxin. What is the most important assessment before administering this medication?
- A. Check blood pressure
- B. Assess heart rate
- C. Monitor respiratory rate
- D. Measure oxygen saturation
Correct answer: B
Rationale: The correct answer is to assess the heart rate before administering digoxin. Digoxin can lead to bradycardia, making it crucial to evaluate the heart rate to prevent potential complications. Checking blood pressure (Choice A) is important but not as critical as assessing the heart rate in this context. Monitoring respiratory rate (Choice C) and measuring oxygen saturation (Choice D) are not the most crucial assessments before administering digoxin, as the primary concern with this medication is its impact on heart rate.
5. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions?
- A. Tossed salad with low-sodium dressing, bacon, and tomato sandwich.
- B. New England clam chowder, unsalted crackers, fresh fruit salad.
- C. Skim milk, turkey salad, roll, and vanilla ice cream.
- D. Macaroni and cheese, diet Coke, and a slice of cherry pie.
Correct answer: C
Rationale: The correct answer is C: Skim milk, turkey salad, roll, and vanilla ice cream. These items are low in sodium, making it a suitable meal for someone on a low-sodium diet. Skim milk, turkey salad, and vanilla ice cream are naturally low in sodium, while the roll can be selected as a low-sodium option. Choices A, B, and D contain items that are typically high in sodium, such as bacon, clam chowder, crackers, and cheese, making them unsuitable for a low-sodium diet.