HESI LPN
Community Health HESI Practice Exam
1. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct answer: C
Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distention.
2. Which type of practice is most similar to research-based practice?
- A. Best practices
- B. Evidence-based practice
- C. Benchmark practices
- D. Standard-based practice
Correct answer: B
Rationale: The correct answer is B: Evidence-based practice. Evidence-based practice relies on research to guide clinical decisions, mirroring the approach of research-based practice. Choice A, Best practices, refers to established methods or techniques that are widely accepted as superior. Choice C, Benchmark practices, typically involves setting standards or goals for performance comparison. Choice D, Standard-based practice, usually pertains to adhering to established norms or guidelines.
3. How does the home care nurse determine that a 78-year-old client is unable to remain in his current residence alone?
- A. The goals set by the client
- B. The learning level of the client
- C. Assessing the home environment
- D. The distractions in the client's home
Correct answer: C
Rationale: The correct answer is assessing the home environment. This process is vital in evaluating whether an elderly client can safely live independently. Factors like safety hazards and the client's ability to handle daily activities are considered during this assessment. Choices A, B, and D are incorrect because determining the client's ability to remain in his residence alone relies more on evaluating the home environment for safety and suitability rather than the client's goals, learning level, or distractions in the home.
4. A nurse is evaluating a client’s use of a cane. What is the correct use?
- A. Client holds the cane on the stronger side of the body.
- B. Client holds the cane on the weaker side of the body.
- C. Client holds the cane in front of the weaker side of the body.
- D. Client holds the cane in front of the stronger side of the body.
Correct answer: A
Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.
5. A client is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12 hours. The available concentration is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)
- A. 0.6 mL
- B. ---
- C. ---
- D. ---
Correct answer: A
Rationale: Calculation: (6 mg/dose) / (10 mg/mL) = 0.6 mL per dose. The correct answer is 0.6 mL. This calculation is obtained by dividing the dose needed (6 mg) by the concentration available (10 mg/mL). The resulting value is 0.6 mL per dose. Choices B, C, and D are not applicable as the correct answer has been calculated accurately.