HESI LPN
Leadership and Management HESI Test Bank
1. Select the tactile sensation that is accurately paired with its description or procedure for testing.
- A. Fine motor coordination: The use of the fingers
- B. Stereognosis: Equal hearing in both ears
- C. Two-point discrimination: The nurse gently pricks the patient's skin
- D. Gross motor function: The use of the lower limbs
Correct answer: C
Rationale: The correct answer is C: Two-point discrimination: The nurse gently pricks the patient's skin. Two-point discrimination assesses the ability to discern two points touched simultaneously on the skin. Fine motor coordination (Choice A) refers to the precise movements of small muscles, not related to tactile sensation. Stereognosis (Choice B) is the ability to recognize objects by touch, not equal hearing in both ears. Gross motor function (Choice D) involves the coordination of large muscle groups, not specifically related to tactile sensation testing.
2. The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
- A. Tell the UAP to use a larger cuff at the next scheduled assessment.
- B. Reassess the client's blood pressure using a larger cuff.
- C. Have the unit educator review this procedure with the UAPs.
- D. Teach the UAP the correct technique for assessing blood pressure.
Correct answer: B
Rationale: Reassessing the client's blood pressure using a larger cuff is the most important action for the nurse to implement in this situation. Using the correct cuff size is crucial for obtaining accurate blood pressure readings. By reassessing with a larger cuff, the nurse can ensure an accurate measurement and proper monitoring of the client's blood pressure. Choice A is not the best option as it doesn't address the immediate need for accurate blood pressure measurement. Choice C is not the most appropriate action at this time since the immediate concern is ensuring correct blood pressure assessment. Choice D, while important, is not the most critical step in this scenario where immediate reassessment is needed with the correct cuff size.
3. What assessment findings should lead the nurse to suspect Down syndrome in a newborn?
- A. Hypertonia and dark skin
- B. Low-set ears and a simian crease
- C. Inner epicanthal folds and a high, domed forehead
- D. Long, thin fingers and excessive hair
Correct answer: B
Rationale: The correct answer is B: 'Low-set ears and a simian crease.' These are key physical characteristics commonly seen in newborns with Down syndrome. Low-set ears, along with a simian crease (a single palmar crease), are indicative of Down syndrome. Choices A, C, and D are incorrect because hypertonia, dark skin, inner epicanthal folds, a high, domed forehead, long, thin fingers, and excessive hair are not specific features associated with Down syndrome in newborns. Therefore, the presence of low-set ears and a simian crease should raise suspicion for Down syndrome and prompt further evaluation.
4. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?
- A. Use a 25-gauge needle.
- B. Select a site on the client’s abdomen.
- C. Use the Z-track technique to displace the skin on the injection site.
- D. Observe for bleb formation to confirm proper placement.
Correct answer: B
Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.
5. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
- A. Ask the client about gastrointestinal pain
- B. Measure the client’s fluid intake and output
- C. Monitor the client’s serum electrolyte levels
- D. Auscultate for bowel sounds in all quadrants
Correct answer: A
Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.