HESI LPN
HESI Practice Test for Fundamentals
1. During an abdominal examination, a nurse in a provider’s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
- A. Fat
- B. Fluid
- C. Flatus
- D. Hernias
Correct answer: D
Rationale: The correct answer is 'Hernias.' Abdominal distention with a midline protrusion, taut skin, and no involvement of the flanks is characteristic of hernias. Hernias are caused by a weakness in the abdominal wall, allowing organs or tissues to protrude through. Fluid accumulation (ascites) typically presents with a more generalized distention, while fat accumulation may cause more diffuse distension rather than a focal midline protrusion. Flatus, or gas, would not typically present with a visible midline protrusion and taut skin like hernias.
2. After instituting ordered measures to reduce the fever in a 3-year-old with fever and vomiting, what nursing action is most important for the nurse in the emergency department to take?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct answer: A
Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.
3. An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. How should the nurse respond?
- A. It limits the chance of vomiting.
- B. It allows the feeding to be administered rapidly.
- C. The energy that would have been expended on sucking is conserved.
- D. The quantity of nutritional liquid can be regulated better than with a bottle.
Correct answer: C
Rationale: The correct answer is C: 'The energy that would have been expended on sucking is conserved.' Gavage feedings are necessary for infants with congenital heart defects as they help conserve the infant’s energy by eliminating the need for sucking, which can be taxing for infants with cardiac issues. Choice A is incorrect because gavage feedings are not primarily used to limit vomiting. Choice B is incorrect as the speed of administration is not the main reason for gavage feedings in this case. Choice D is incorrect because the regulation of the quantity of nutritional liquid is not the primary rationale for gavage feedings in infants with congenital heart defects.
4. What should be included in the medical management of sickle cell crisis?
- A. Information for the parents including home care
- B. Provisions for adequate hydration and pain management
- C. Pain management and administration of iron supplements
- D. Adequate oxygenation and factor VIII
Correct answer: B
Rationale: The correct answer is B: Provisions for adequate hydration and pain management. In managing a sickle cell crisis, it is essential to provide adequate hydration to prevent further sickling of red blood cells and ensure proper pain management to alleviate the severe pain associated with the crisis. While information for parents and home care may be important aspects of overall care, they are not specific to the immediate medical management of a sickle cell crisis. Administration of iron supplements is not recommended during a sickle cell crisis as it can potentially worsen the condition by promoting the production of more sickled red blood cells. Adequate oxygenation is crucial in sickle cell disease, but factor VIII is not typically part of the management of a sickle cell crisis.
5. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?
- A. Offer ice chips every 2 hours
- B. Place the child in a semi-Fowler's position
- C. Encourage the child to drink from a cup
- D. Observe swallowing patterns
Correct answer: D
Rationale: Observing swallowing patterns is crucial post-tonsillectomy and adenoidectomy to detect signs of bleeding. Offering ice chips instead of ice cream helps prevent throat irritation. Placing the child in a semi-Fowler's position promotes airway patency and reduces the risk of aspiration. Encouraging the child to drink from a cup instead of a straw minimizes the risk of dislodging the surgical site.