HESI LPN
HESI Fundamentals 2023 Test Bank
1. A nurse receives a report about a client receiving IV fluids infusing at 125 mL/hr but notes they have only received 80 mL over the last 2 hours. What should the nurse do first?
- A. Check IV tubing for obstruction
- B. Increase the flow rate
- C. Change the IV site
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for the nurse to take is to check the IV tubing for obstruction. This step is crucial in ensuring that the IV fluids are flowing properly and that there are no blockages preventing the correct infusion rate. Increasing the flow rate (Choice B) without confirming the tubing's status could lead to potential complications if there is indeed an obstruction. Changing the IV site (Choice C) is not the priority in this situation unless there are specific clinical indications. Notifying the physician (Choice D) can be done after checking the tubing for obstruction, as the physician may need to be informed depending on the findings.
2. A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Muscle spasms
- C. Drowsiness
- D. Tachycardia
Correct answer: C
Rationale: The correct answer is C: Drowsiness. Baclofen, a muscle relaxant commonly used to treat conditions like multiple sclerosis, can cause drowsiness as a side effect. Monitoring for drowsiness is important to ensure the client's safety and well-being. Choice A, Hypertension, is incorrect because baclofen is not known to cause hypertension. Choice B, Muscle spasms, is not a common side effect of baclofen but rather the symptom it is used to treat. Choice D, Tachycardia, is also incorrect as baclofen is not associated with causing an increase in heart rate.
3. The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
- A. Increased serum glucose
- B. Decreased albumin
- C. Decreased potassium
- D. Increased sodium retention
Correct answer: C
Rationale: The correct answer is C, 'Decreased potassium.' Clients with bulimia often have decreased potassium levels due to frequent vomiting, which causes a loss of this essential electrolyte. This loss can lead to various complications such as cardiac arrhythmias. Option A, 'Increased serum glucose,' is not typically associated with bulimia. Option B, 'Decreased albumin,' is more related to malnutrition or liver disease rather than bulimia. Option D, 'Increased sodium retention,' is not a common finding in clients with bulimia; instead, they may experience electrolyte imbalances like hyponatremia due to purging behaviors.
4. Which presentation of an infectious disease is acquired through an indirect transmission?
- A. Syphilis contracted from a sexual partner.
- B. Measles resulting from a daycare center outbreak.
- C. Malaria following exposure in a mosquito-infested area.
- D. Nosocomial influenza spreading rapidly in a long-term care center.
Correct answer: C
Rationale: The correct answer is C. Malaria is transmitted indirectly through mosquito bites. Choice A is incorrect as syphilis is acquired through direct contact with an infected sexual partner. Choice B is incorrect as measles can be transmitted through respiratory droplets in close contact settings like daycare centers. Choice D is incorrect as nosocomial influenza spreads within healthcare facilities through direct contact or droplets.
5. An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the health care provider?
- A. 100 to 150 mL
- B. 155 to 250 mL
- C. 255 to 360 mL
- D. 365 to 500 mL
Correct answer: B
Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.