HESI LPN
Fundamentals HESI
1. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer?
- A. 1 ml.
- B. 1.5 ml.
- C. 1.75 ml.
- D. 2 ml.
Correct answer: B
Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.
2. The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?
- A. Ensure that the client’s circulation is checked every hour.
- B. Document the reason for the restraints every 4 hours.
- C. Provide range-of-motion exercises every 2 hours.
- D. Release the restraints every 2 hours for repositioning.
Correct answer: D
Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.
3. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.
4. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?
- A. Nasal congestion
- B. Cough
- C. Sore throat
- D. Fatigue
Correct answer: C
Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.
5. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
- A. Immediately after exhalation.
- B. During the inhalation.
- C. At the end of three inhalations.
- D. Immediately after inhalation.
Correct answer: B
Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.
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