HESI LPN
HESI Fundamentals Exam
1. The healthcare professional prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The healthcare professional should regulate the IV to administer approximately how many drops per minute?
- A. 80
- B. 8
- C. 21
- D. 25
Correct answer: C
Rationale: To calculate the drops per minute for the IV infusion, first determine the total drops to be infused over 8 hours. 1,000 ml to be infused over 8 hours means 125 ml per hour (1000 ml / 8 hours = 125 ml/hr). Since the infusion set delivers 10 drops per ml, 125 ml/hr x 10 drops/ml = 1250 drops/hr. To find drops per minute, divide the drops per hour by 60 (minutes in an hour): 1250 drops/hr / 60 minutes = 20.83 drops/minute, which rounds up to 21 drops per minute (Option C). This rate ensures the correct infusion rate over 8 hours. Choices A, B, and D are incorrect calculations and do not provide the appropriate infusion rate needed to administer the IV over the specified time period.
2. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug?
- A. Bleeding time
- B. Coagulation time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct answer: C
Rationale: The correct answer is C: Prothrombin time (PT). Prothrombin time is monitored to assess the therapeutic response to warfarin therapy. Warfarin works by inhibiting vitamin K-dependent clotting factors, which prolongs the PT. Monitoring PT helps determine if the client's blood is clotting within the desired therapeutic range. Choices A, B, and D are incorrect because bleeding time, coagulation time, and partial thromboplastin time are not specifically used to monitor the therapeutic response to warfarin. Bleeding time assesses platelet function, coagulation time is a general term and not a specific test, and partial thromboplastin time is more relevant in monitoring heparin therapy, not warfarin.
3. The appropriate order of steps in active management of the third stage of labor includes:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to ensure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage.
- C. Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage.
- D. Controlled cord traction, fundal massage, and oxytocin.
Correct answer: C
Rationale: The correct sequence of steps in active management of the third stage of labor includes intramuscular injection of oxytocin to prevent postpartum hemorrhage, controlled cord traction with counter traction to the uterus to facilitate placental delivery, and uterine massage to aid in uterine contraction and prevent excessive bleeding. Choice A is incorrect because ergometrine administration is not routinely recommended in active management. Choice B is incorrect as intravenous oxytocin is not the preferred route of administration. Choice D is incorrect as the order of steps is not accurate.
4. A client with a diagnosis of depression is prescribed fluoxetine. Which statement by the client indicates the need for further teaching?
- A. I should take this medication in the morning with food.
- B. It may take 1 to 4 weeks to notice improvement in symptoms.
- C. I can stop taking this medication once I feel better.
- D. This medication might make me feel drowsy.
Correct answer: C
Rationale: The correct answer is C. Clients prescribed fluoxetine should not stop taking the medication once they feel better without consulting their healthcare provider. It is essential to complete the full course of treatment as directed by the healthcare provider to prevent relapse or potential worsening of symptoms. Abruptly stopping fluoxetine can lead to withdrawal symptoms and may not effectively manage the condition. Therefore, it is crucial for clients to follow the healthcare provider's guidance regarding the duration of treatment with fluoxetine.
5. What is an important basis in preparing the family health care plan?
- A. Needs and problems gathered and recognized by the nurse herself
- B. Data gathered from the health center
- C. Needs and problems as seen and accepted by the family
- D. Needs as expected by the midwife assigned in the area where the family resides
Correct answer: C
Rationale: In preparing a family health care plan, it is crucial to consider the needs and problems as perceived and accepted by the family members themselves. This ensures that the plan aligns with the family's beliefs, values, and preferences, leading to better acceptance and adherence. Choices A, B, and D are incorrect because the active involvement and acceptance of the family in recognizing their needs and problems are essential for effective health care planning.