HESI LPN
Practice HESI Fundamentals Exam
1. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?
- A. Insert an oral airway.
- B. Place the patient in a flat, supine position.
- C. Use undiluted hydrogen peroxide as a cleaner.
- D. Quickly proceed without talking to the patient.
Correct answer: A
Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.
2. When planning to administer the antiulcer GI agent sucralfate, what instruction should the nurse provide regarding administration?
- A. Administer sucralfate once a day
- B. Assess for secondary candida infection
- C. Monitor electrolyte imbalance
- D. Give sucralfate on an empty stomach
Correct answer: D
Rationale: Sucralfate is most effective when taken on an empty stomach. This allows the medication to form a protective layer over the ulcer, promoting healing and symptom relief. Administering sucralfate with or after meals may reduce its efficacy as it may bind to food instead of coating the ulcer site.
3. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.
4. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?
- A. 0.75 mL
- B. 1 mL
- C. 0.8 mL
- D. 1.2 mL
Correct answer: C
Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.
5. After an infant has had corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?
- A. Rock the infant.
- B. Place the infant in an infant seat.
- C. Place the infant flat on the right side.
- D. Keep the infant awake with sensory stimulation.
Correct answer: B
Rationale: Correct Answer: B. Placing the infant in an infant seat is essential after feeding to help keep the head elevated and reduce the risk of vomiting. This position helps prevent regurgitation of formula or milk. Rocking the infant (Choice A) is incorrect because it may exacerbate vomiting due to the movement. Placing the infant flat on the right side (Choice C) is incorrect as it does not promote proper digestion and can increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) is incorrect as it does not directly address the physiological need to reduce vomiting after feeding.