HESI LPN
Fundamentals of Nursing HESI
1. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?
- A. Calf swelling
- B. Elevated blood pressure
- C. Decreased urine output
- D. Generalized rash
Correct answer: A
Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.
2. Which statement best describes the composition of most foods?
- A. Most foods contain a mixture of the three energy nutrients, with one or two predominating.
- B. Foods do not typically contain equal amounts of the three energy nutrients.
- C. Most foods contain mixtures of the three energy nutrients, although only one or two may predominate.
- D. Most foods contain all three energy nutrients in varying amounts.
Correct answer: C
Rationale: The correct answer is C. Most foods contain a mixture of the three energy nutrients (carbohydrates, proteins, fats), with one or two predominating. Choice A is correct because most foods do contain a combination of energy nutrients, with one or two types usually being predominant. Choice B is incorrect as foods typically do not contain equal amounts of carbohydrates, proteins, and fats. Choice D is incorrect because most foods contain all three energy nutrients, not just one or two types.
3. A client diagnosed with angina has been prescribed nitrate isosorbide dinitrate. Which instruction should the practical nurse reinforce in this client's teaching?
- A. Discontinue the medication if dizziness occurs.
- B. Avoid getting up quickly. Always rise slowly.
- C. Take the medication with or without food.
- D. Increase your intake of potassium-rich foods.
Correct answer: B
Rationale: The correct instruction that the practical nurse should reinforce with a client prescribed nitrate isosorbide dinitrate is to avoid getting up quickly and to rise slowly. Nitrates can cause orthostatic hypotension, a sudden drop in blood pressure when changing positions. By rising slowly, the client can prevent the occurrence of orthostatic hypotension and its associated symptoms. Choices A, C, and D are incorrect because discontinuing the medication without consulting a healthcare provider can be dangerous, taking the medication with or without food does not impact its effectiveness, and increasing potassium intake is not directly related to the use of nitrate isosorbide dinitrate.
4. When discussing the side effects of the Haemophilus influenzae (Hib) vaccine with parents, which sign should the nurse mention for an infant receiving the vaccine?
- A. Lethargy
- B. Urticaria
- C. Generalized rash
- D. Low-grade fever
Correct answer: D
Rationale: The correct answer is 'Low-grade fever.' A low-grade fever is a typical, mild side effect that can occur after the Hib vaccine is administered. It is a sign that the body's immune system is responding to the vaccine and is generally not a cause for concern. Lethargy, urticaria, and generalized rash are not commonly associated side effects of the Hib vaccine. Lethargy may be a sign of other issues, while urticaria and generalized rash are more indicative of allergic reactions rather than typical responses to the Hib vaccine.
5. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?
- A. Decreased thyroid stimulating hormone level
- B. Elevated liver function profile
- C. Increased white blood cell count
- D. Decreased hematocrit and hemoglobin levels
Correct answer: A
Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.