HESI LPN
Community Health HESI Practice Exam
1. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?
- A. Hepatitis C (HepC)
- B. Influenza type B (HIB)
- C. Measles, mumps, rubella (MMR)
- D. Diphtheria, tetanus, pertussis (DTaP)
Correct answer: C
Rationale: The correct answer is C: Measles, mumps, rubella (MMR). MMR vaccine is commonly included in precollege physicals to ensure students are protected against these diseases. Choice A, Hepatitis C (HepC), is incorrect as the standard vaccine for hepatitis given in childhood is Hepatitis B. Choice B, Influenza type B (HIB), is not typically administered during precollege physicals but is recommended for younger children. Choice D, Diphtheria, tetanus, pertussis (DTaP), is usually given in early childhood and not typically repeated during precollege physicals.
2. Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?
- A. Pedal pulses
- B. Breath sounds
- C. Oxygen saturation
- D. Blood pressure
Correct answer: D
Rationale: The correct answer is 'D: Blood pressure.' It is crucial to check the client's blood pressure before ambulating them, especially if they have a history of syncope. Monitoring blood pressure helps to prevent falls by ensuring that the client's blood pressure is stable enough to tolerate the activity. Choices A, B, and C are not as critical in this scenario. Checking pedal pulses, breath sounds, or oxygen saturation is important but not as crucial as assessing blood pressure when preparing to ambulate a client with a history of syncope.
3. In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
- A. Shallow open ulcer with a red-pink wound bed.
- B. Intact skin with non-blanchable redness.
- C. Full-thickness tissue loss with visible fat.
- D. Full-thickness tissue loss with exposed bone, tendon, or muscle.
Correct answer: A
Rationale: The correct answer is A: 'Shallow open ulcer with a red-pink wound bed.' Stage 2 pressure ulcers involve partial-thickness skin loss and typically appear as shallow open ulcers with a red-pink wound bed. Choice B describes a stage 1 ulcer, where the skin is intact but shows non-blanchable redness. Choice C describes a stage 3 ulcer, with full-thickness tissue loss exposing fat. Choice D is characteristic of a stage 4 ulcer, where there is full-thickness tissue loss exposing bone, tendon, or muscle. Therefore, option A best fits the description of a stage 2 pressure ulcer.
4. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned, and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct answer: B
Rationale: In the scenario described, the nurse notes late decelerations during contractions despite repositioning and oxygen administration. Late decelerations are often associated with uteroplacental insufficiency, which can be exacerbated by increased uterine activity stimulated by oxytocin. The initial action to manage late decelerations is to turn off the oxytocin infusion to reduce uterine stimulation. This step aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth may be necessary if the late decelerations persist or worsen despite discontinuing the oxytocin infusion. Notifying the anesthesiologist to disconnect the epidural infusion or applying an internal fetal monitoring device are not the first-line interventions for managing late decelerations.
5. To prevent keratitis in an unconscious client, where should the nurse apply moisturizing ointment?
- A. Finger and toenail quicks
- B. Eyes
- C. Perianal area
- D. External ear canals
Correct answer: B
Rationale: The correct answer is B: Eyes. Applying moisturizing ointment to the eyes helps prevent keratitis, a condition that can occur due to inadequate blinking in unconscious clients, leading to corneal dryness and potential damage. Choices A, C, and D are incorrect as moisturizing ointment should not be applied to finger and toenail quicks, perianal area, or external ear canals to prevent keratitis.