HESI LPN
HESI Fundamentals Test Bank
1. A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client’s abdomen, the nurse expects the bowel sounds to be:
- A. Absent
- B. Hyperactive
- C. Normal
- D. Hypoactive
Correct answer: A
Rationale: In paralytic ileus, bowel sounds are typically absent or significantly reduced due to decreased motility of the intestines. This absence of bowel sounds is a key characteristic used in diagnosing paralytic ileus. Hyperactive bowel sounds are not expected in this condition as there is a lack of normal peristalsis. Normal bowel sounds would not be present in paralytic ileus, and hypoactive bowel sounds, which indicate decreased bowel motility, are more commonly associated with conditions like postoperative ileus or constipation, rather than paralytic ileus.
2. A client with bipolar disorder is receiving lithium (Lithobid). The nurse should monitor the client for which of the following side effects?
- A. Hypernatremia
- B. Hyponatremia
- C. Hyperglycemia
- D. Hypercalcemia
Correct answer: B
Rationale: The correct answer is B: Hyponatremia. Lithium can lead to hyponatremia by affecting sodium balance in the body. Hypernatremia (Choice A) is unlikely with lithium use. Hyperglycemia (Choice C) and hypercalcemia (Choice D) are not typically associated with lithium therapy for bipolar disorder.
3. A client with chronic heart failure is prescribed furosemide. The nurse should monitor the client for which potential adverse effect?
- A. Increased blood glucose levels
- B. Electrolyte imbalance
- C. Dehydration
- D. Weight gain
Correct answer: C
Rationale: When a client with chronic heart failure is prescribed furosemide, a diuretic, the nurse should be vigilant for potential adverse effects. Furosemide can lead to excessive fluid loss, resulting in dehydration. Dehydration is a significant concern as it can exacerbate heart failure symptoms. Additionally, furosemide can cause electrolyte imbalances, particularly affecting potassium and sodium levels. Monitoring for signs of dehydration and electrolyte disturbances is crucial to prevent complications and ensure the client's safety and well-being. Increased blood glucose levels and weight gain are not commonly associated with furosemide use in heart failure patients, making choices A and D incorrect.
4. An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department, and her arm placed in a cast. At 11 p.m., her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?
- A. Notifying the doctor immediately
- B. Applying ice
- C. Elevating the arm
- D. Giving additional pain medication as ordered
Correct answer: A
Rationale: The correct action would be to notify the doctor immediately. Unrelenting pain despite medication can indicate compartment syndrome, which is a medical emergency requiring immediate attention. Applying ice or elevating the arm may not address the potential serious underlying issue of compartment syndrome. Giving additional pain medication without further assessment could delay necessary intervention and potentially worsen the condition.
5. A female client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. What is the priority nursing intervention?
- A. Monitor the client's vital signs regularly.
- B. Encourage the client to participate in group therapy.
- C. Offer the client frequent, high-calorie snacks.
- D. Weigh the client daily at the same time.
Correct answer: D
Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.