HESI LPN
Community Health HESI Practice Exam
1. When the nurse identifies what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction, the first action the nurse should perform is to
- A. Begin cardiopulmonary resuscitation
- B. Prepare for immediate defibrillation
- C. Notify the 'Code' team and healthcare provider
- D. Assess airway, breathing, and circulation
Correct answer: D
Rationale: The correct first action for the nurse to take when identifying what appears to be ventricular tachycardia in a client being evaluated for possible myocardial infarction is to assess the client's airway, breathing, and circulation. This step is crucial to determine the client's stability and the need for immediate intervention. Beginning cardiopulmonary resuscitation or preparing for immediate defibrillation without first assessing the airway, breathing, and circulation could delay potentially life-saving interventions. Notifying the 'Code' team and healthcare provider should come after ensuring the client's immediate needs are addressed.
2. During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?
- A. Follow a systematic pattern from side-to-side moving down the client’s chest.
- B. Ask the client to breathe in deeply through their nose.
- C. Instruct the client to sit upright with their head slightly tilted backward.
- D. Place the diaphragm of the stethoscope on the client’s chest.
Correct answer: A
Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client’s chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client’s chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.
3. The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?
- A. Increase the intake of spicy foods
- B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
- C. Drink coffee in moderation
- D. Eat large meals at bedtime
Correct answer: B
Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.
4. Which anatomic malformations are associated with Tetralogy of Fallot?
- A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
- B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
- C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
- D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow
Correct answer: D
Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.
5. Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?
- A. Performing oral care with chlorhexidine
- B. Elevating the head of the bed to 30-45 degrees
- C. Administering prophylactic antibiotics
- D. Changing the ventilator circuit daily
Correct answer: B
Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.