HESI LPN
HESI Fundamentals 2023 Quizlet
1. The LPN/LVN is assisting with the care of a client who has just had a liver biopsy. What position should the nurse place the client in immediately following the procedure?
- A. Supine with the right arm raised above the head
- B. Supine with the head of the bed elevated
- C. Right side-lying with a pillow under the costal margin
- D. Left side-lying with the head of the bed flat
Correct answer: C
Rationale: The correct position for a client immediately following a liver biopsy is right side-lying with a pillow under the costal margin. This position helps prevent bleeding by applying pressure to the biopsy site. Placing the client supine with the right arm raised above the head (Choice A) or supine with the head of the bed elevated (Choice B) are not ideal positions for post-liver biopsy care as they do not provide the necessary pressure to the biopsy site. Left side-lying with the head of the bed flat (Choice D) is also not recommended as it does not assist in preventing bleeding after a liver biopsy.
2. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?
- A. Changes in mental status
- B. Urine output and color
- C. Blood pressure and heart rate
- D. Skin turgor
Correct answer: A
Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.
3. A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe?
- A. Erythematous papulovesicular rash
- B. Dry, red, scaly rash with lichenification
- C. Pustular vesicles with honey-colored exudates
- D. Hypopigmented oval scaly lesions
Correct answer: B
Rationale: In atopic dermatitis, the nurse would expect to observe a dry, red, scaly rash with lichenification. Lichenification is thickened skin due to chronic scratching. Choices A, C, and D are incorrect. Erythematous papulovesicular rash is more characteristic of contact dermatitis, pustular vesicles with honey-colored exudates are seen in impetigo, and hypopigmented oval scaly lesions are typical of pityriasis alba.
4. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?
- A. Check for tightness of the cast
- B. Elevate the limb
- C. Apply ice to the area
- D. Notify the physician
Correct answer: A
Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.
5. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?
- A. Measure the client's vital signs.
- B. Assess the client's pain level.
- C. Verify the morphine order with another nurse.
- D. Check the client's last dose of morphine.
Correct answer: A
Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.