HESI LPN
HESI Practice Test for Fundamentals
1. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?
- A. Capillary refill of 4 seconds
- B. 7.5 cm (3 in) diameter bruise on the ankle
- C. Warts on the affected ankle
- D. 2+ pitting edema
Correct answer: A
Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.
2. Select the ethical principles that are paired with their descriptions. Select the one that does not apply.
- A. Justice: Being honest and fair
- B. Beneficence: Doing good
- C. Veracity: Truthfulness
- D. Self-determination: Facilitating patient choices
Correct answer: C
Rationale: The correct answer is C. Veracity is the principle of truthfulness, not treating all patients equally. Choice A is correct as Justice involves being honest and fair. Choice B is correct as Beneficence is about doing good. Choice D is correct as Self-determination is about respecting and facilitating patient choices.
3. A client is about to undergo emergency abdominal surgery for appendicitis. A healthcare professional is demonstrating postoperative deep breathing and coughing exercises to the client. The healthcare professional realizes the client may be unprepared to learn if the client:
- A. Is not feeling well
- B. Reports severe pain
- C. Has low blood pressure
- D. Is anxious
Correct answer: B
Rationale: Severe pain can be a significant distraction and impediment to the learning process. When a client is experiencing severe pain, their focus and attention are primarily directed towards managing the pain, making it difficult for them to absorb and retain new information effectively. Options A, C, and D, although important considerations in a healthcare setting, do not directly impact the client’s ability to learn in the same way that severe pain does. Not feeling well, low blood pressure, and anxiety are all factors that can be addressed or managed to facilitate learning, unlike severe pain which can significantly hinder the learning process.
4. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
- A. Erythema along the path of the vein
- B. Pitting edema at the insertion site
- C. Coolness of the client’s left forearm
- D. Pallor of the client’s left forearm
Correct answer: A
Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.
5. You are caring for a 6-year-old child with a possible fractured left arm and have reason to believe that the child was abused. How should you manage this situation?
- A. Inform the parents of your suspicions.
- B. Call the police so the parents can be arrested.
- C. Advise the parents that the child needs to be transported.
- D. Transport the child to the hospital regardless of the parents' wishes.
Correct answer: C
Rationale: In cases where child abuse is suspected, it is crucial to prioritize the safety and well-being of the child. Advising the parents that the child needs to be transported allows for the child to receive necessary medical care without immediate confrontation. Calling the police to have the parents arrested (Choice B) may escalate the situation and should only be done after ensuring the child's safety. Informing the parents of suspicions (Choice A) may potentially place the child at further risk if the parents are the abusers. Transporting the child to the hospital regardless of the parents' wishes (Choice D) could lead to legal and ethical complications; it is important to involve the appropriate authorities and handle the situation with sensitivity and care.