HESI LPN
HESI Fundamentals Test Bank
1. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?
- A. Ask the client if he is okay.
- B. Call security from the room.
- C. Find out if there is anyone else in the room.
- D. Ask security to make sure the room is safe.
Correct answer: D
Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.
2. The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
- A. Consult the healthcare provider for recommendations on pain management
- B. Schedule the client for physical therapy to manage pain
- C. Recommend the client attend a support group for cancer patients
- D. Suggest alternative therapies like acupuncture or massage
Correct answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
3. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?
- A. Check the placement of the tube by auscultation.
- B. Flush the tube with 30 ml of water before and after medication administration.
- C. Administer the medication with food to prevent nausea.
- D. Dilute the medication with normal saline before administration.
Correct answer: B
Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.
4. A healthcare professional is reviewing a client's laboratory report and notes that the serum calcium level is 4.0 mg/dL. The healthcare professional understands that which condition most likely caused this serum calcium level?
- A. Prolonged bed rest
- B. Renal insufficiency
- C. Hyperparathyroidism
- D. Excessive ingestion of vitamin D
Correct answer: A
Rationale: Prolonged bed rest can lead to hypocalcemia due to decreased mobility and bone resorption. In this scenario, the low serum calcium level of 4.0 mg/dL is likely a result of decreased bone activity and calcium release due to prolonged bed rest. Renal insufficiency would more likely lead to hypercalcemia due to impaired excretion of calcium by the kidneys. Hyperparathyroidism is characterized by increased calcium levels as a result of excess parathyroid hormone. Excessive ingestion of vitamin D can cause hypercalcemia by increasing intestinal absorption of calcium.
5. A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?
- A. This condition is due to a genetic defect in the bones.
- B. It's most likely from how the baby was positioned in utero.
- C. They really don't know what causes this condition.
- D. There is probably an underlying deformity of the baby's hip.
Correct answer: B
Rationale: Metatarsus adductus is a condition where the front part of the foot is turned inward. It is often caused by the baby's position in the womb, leading to pressure on the foot during fetal development. Choice A is incorrect as metatarsus adductus is not primarily caused by a genetic defect in the bones. Choice C is incorrect as the cause of metatarsus adductus is known to be related to intrauterine positioning. Choice D is incorrect as metatarsus adductus specifically pertains to the foot and not the hip.