a nurse uses a head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week which of the following cr
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?

Correct answer: D

Rationale: The correct answer is 'Discipline.' In this scenario, discipline is exemplified by following a structured and comprehensive assessment process, as seen in the head-to-toe approach. Confidence (choice A) relates to self-assurance and belief in one's abilities, which is not the primary critical thinking demonstrated in this situation. Perseverance (choice B) is the persistence in achieving goals despite challenges, not directly related to the systematic assessment process. Integrity (choice C) pertains to honesty and ethical behavior, which are important traits but not the critical thinking skill exemplified by the structured assessment process shown in the head-to-toe approach.

2. A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?

Correct answer: A

Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.

3. During a physical assessment, a nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use?

Correct answer: A

Rationale: The correct answer is to ensure the bladder of the BP cuff surrounds 80% of the arm. This technique is crucial for obtaining accurate blood pressure readings. Choice B is incorrect because using the BP cuff on the forearm may lead to inaccurate readings. Choice C is incorrect as applying the BP cuff loosely can also result in inaccurate measurements. Choice D is incorrect because using a pediatric cuff for adults with small arms would not provide accurate blood pressure readings.

4. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?

Correct answer: A

Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.

5. The healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?

Correct answer: D

Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, which requires immediate attention. The presence of crepitus suggests air leaking into the tissues, which could lead to respiratory compromise. Constant bubbling in the suction control chamber is expected and indicates proper functioning of the chest tube system. Intermittent bubbling in the water seal chamber is also normal, showing the system is intact. Drainage of 50 ml per hour is within the expected range for a chest tube.

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