HESI LPN
Fundamentals of Nursing HESI
1. An assistive personnel tells the nurse, 'I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?' The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is:
- A. Low
- B. High
- C. Inaccurate
- D. Unaffected
Correct answer: B
Rationale: Using a regular blood pressure cuff on a morbidly obese client will lead to a falsely high blood pressure reading. This occurs because the cuff is not appropriately sized for the client's arm circumference, resulting in increased pressure on the artery and an inaccurate high reading. Choice A is incorrect because the reading will be falsely high, not low. Choice C is incorrect as the reading will not be accurate with an incorrectly sized cuff. Choice D is incorrect because the reading will be affected by using the wrong cuff size.
2. The healthcare professional is preparing a presentation to a local community group about genetic disorders and the types of congenital anomalies that can occur. What would the professional include as a major congenital anomaly?
- A. Overlapping digits
- B. Polydactyly
- C. Umbilical hernia
- D. Cleft palate
Correct answer: D
Rationale: Cleft palate is considered a major congenital anomaly due to its significant impact on feeding, speech, and overall health. Overlapping digits (Option A) are a physical anomaly but not typically considered a major congenital anomaly. Polydactyly (Option B) refers to having extra fingers or toes, which is a congenital anomaly but not as major as a cleft palate. Umbilical hernia (Option C) involves a protrusion of abdominal contents through the umbilical ring but is not typically classified as a major congenital anomaly compared to cleft palate.
3. 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.
4. What should be assessed first in a child with suspected head trauma?
- A. Response to verbal stimuli
- B. Pupillary reaction
- C. Skin color
- D. Heart rate
Correct answer: A
Rationale: The correct answer is to assess the response to verbal stimuli first in a child with suspected head trauma. This assessment helps in determining the child's level of consciousness and neurological status. Assessing the response to verbal stimuli allows healthcare providers to quickly evaluate if the child is alert, oriented, and able to communicate effectively. This initial assessment is crucial in identifying any immediate concerns related to the child's neurological function. Choices B, C, and D are not the primary assessments in cases of suspected head trauma. While pupillary reaction, skin color, and heart rate are important assessments in trauma situations, assessing the response to verbal stimuli takes precedence in evaluating the neurological status of a child with head trauma.
5. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing?
- A. Serum albumin 3 g/dL
- B. Total lymphocyte count 2400/mm3
- C. HCT 42%
- D. HGB 16 g/dL
Correct answer: A
Rationale: The correct answer is A: Serum albumin 3 g/dL. Low levels of serum albumin indicate poor nutritional status and can impair wound healing. Total lymphocyte count, HCT, and HGB levels are not directly related to wound healing and do not pose a significant risk for poor wound healing in this context. Total lymphocyte count reflects the immune status, HCT measures the percentage of red blood cells in blood, and HGB measures the amount of hemoglobin in blood.