HESI LPN
HESI Fundamentals 2023 Test Bank
1. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?
- A. A client who has nasogastric suctioning
- B. A client who has chronic constipation
- C. A client who has syndrome of inappropriate antidiuretic hormone
- D. A client who took a toxic dose of sodium bicarbonate antacids
Correct answer: A
Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.
2. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?
- A. Fat-free
- B. Protein-enriched
- C. Phenylalanine-free
- D. Low-phenylalanine
Correct answer: D
Rationale: A low-phenylalanine diet is required for infants with PKU to prevent the buildup of phenylalanine, which can lead to brain damage.
3. A cerebrovascular accident patient is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates no extraordinary life-saving measures. What action should the nurse take?
- A. Refer to the risk manager
- B. Notify the healthcare provider
- C. Discontinue the ventilator
- D. Review the medical record
Correct answer: B
Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.
4. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia, what information should the nurse review?
- A. Sputum culture findings
- B. Oxygen saturation level
- C. Amount of coughing
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is A: Sputum culture findings. Reviewing sputum culture findings can provide valuable information to differentiate between bacterial pneumonia and heart failure, as the type of bacteria present in the sputum can help identify the specific infection. Oxygen saturation level (Choice B) is important for assessing oxygenation status but does not directly help in distinguishing between the two conditions based on lung sounds. The amount of coughing (Choice C) and respiratory rate (Choice D) may offer some clinical insights but are not as specific or diagnostic as sputum culture findings when differentiating between heart failure and bacterial pneumonia.
5. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?
- A. Fungi
- B. Friction
- C. Nail polish
- D. Nail polish remover
Correct answer: A
Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.