the mother of a 2 year old hospitalized child asks the nurses advice about the childs screaming every time the mother gets ready to leave the hospital
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?

Correct answer: C

Rationale: The nurse should reassure the mother that the child's behavior is normal for their age and situation.

2. A client with a history of chronic renal failure is admitted with generalized edema. Which laboratory value should the LPN/LVN monitor to assess the client's fluid balance?

Correct answer: C

Rationale: The correct answer is C, Serum albumin. In clients with chronic renal failure and generalized edema, monitoring serum albumin levels is crucial as it is a key indicator of fluid balance. Low serum albumin levels can contribute to edema formation due to decreased oncotic pressure, indicating fluid imbalance. Serum potassium (Choice A) is more related to kidney function and electrolyte balance in renal failure patients. Serum calcium (Choice B) is important for bone health but is not directly related to fluid balance. Serum sodium (Choice D) is more indicative of hydration status and electrolyte balance but may not directly reflect fluid balance in the context of chronic renal failure and edema.

3. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Correct answer: A

Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.

4. A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:

Correct answer: A

Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.

5. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:

Correct answer: A

Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.

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