HESI LPN
HESI Fundamentals Exam
1. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
- A. Reposition the client
- B. Document the client's IV intake in the medical record
- C. Request a new IV fluid prescription
- D. Check the IV tubing for obstruction
Correct answer: D
Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.
2. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
- A. Offer ice chips every 2 hours
- B. Place the child in a semi-Fowler's position
- C. Encourage the child to drink from a cup
- D. Observe swallowing patterns
Correct answer: D
Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.
3. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
- A. Examine the elbow
- B. Administer pain medication
- C. Apply a warm compress to the elbow
- D. Assess the client’s range of motion
Correct answer: A
Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.
4. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct answer: D
Rationale: The correct answer is D: 'Improve team morale.' Self-scheduling allows staff more control over their work hours, which can lead to increased job satisfaction, autonomy, and a sense of ownership over their schedules. This, in turn, fosters a positive work environment, enhances collaboration among team members, and boosts morale. Choices A, B, and C are incorrect because while self-scheduling may indirectly contribute to improved quality of care, decreased staff turnover, and minimized overtime payouts, the primary benefit in this context is the positive impact on team morale.
5. A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving home oxygen therapy. What is the most important instruction the nurse should provide?
- A. Use oxygen at the highest flow rate tolerated.
- B. Do not smoke while using oxygen.
- C. Avoid wearing the oxygen during physical activity.
- D. Store oxygen tanks in a cool, dark place.
Correct answer: B
Rationale: The most important instruction the nurse should provide to a client with COPD receiving home oxygen therapy is not to smoke while using oxygen. Smoking near oxygen can cause a fire or explosion due to the flammable nature of oxygen. Choice A is incorrect because using oxygen at the highest flow rate tolerated without medical supervision can be harmful. Choice C is the correct answer as wearing oxygen during physical activity can increase the risk of oxygen combustion. Choice D is not the most important instruction; while storing oxygen tanks properly is essential, the immediate safety concern is the risk of fire due to smoking near oxygen.