HESI LPN
HESI Fundamentals Test Bank
1. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
- A. Reassess the client to determine the reasons for inadequate pain relief.
- B. Wait to see whether the pain lessens during the next 24 hours.
- C. Change the plan of care to provide different pain relief interventions.
- D. Teach the client about the plan of care for managing pain.
Correct answer: A
Rationale: Reassessing the client is crucial to identify the reasons for inadequate pain relief. This action allows the nurse to gather more information, evaluate the current pain management interventions, and make necessary adjustments to the care plan. Waiting for the pain to lessen without taking action delays appropriate pain management. Changing the plan of care without reassessment may lead to ineffective interventions. Teaching the client about the plan of care should be based on a reassessment of the current pain relief status to ensure tailored and effective pain management strategies.
2. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?
- A. 100% oxygen via partial rebreathing mask
- B. 2 liters per minute via nasal cannula
- C. 4 liters per minute via simple mask
- D. 6 liters per minute via face mask
Correct answer: A
Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.
3. A healthcare professional is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
- A. Ventrogluteal
- B. Dorsogluteal
- C. Deltoid
- D. Vastus lateralis
Correct answer: A
Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.
4. The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?
- A. Night sweats
- B. Weight loss
- C. Cough with bloody sputum
- D. Fatigue
Correct answer: C
Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.
5. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
- A. Every 4 to 8 hours
- B. Every 12 to 24 hours
- C. Every 24 to 48 hours
- D. Every 72 to 96 hours
Correct answer: D
Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.
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