HESI LPN
HESI Fundamental Practice Exam
1. The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.
2. While assessing a child admitted for an asthma attack, a nurse in the emergency department observes large welts and scars on the child's back. What additional information must be included in the nurse’s assessment?
- A. History of an injury
- B. Signs of child abuse
- C. Presence of food allergies
- D. Recent recovery from chickenpox
Correct answer: B
Rationale: The correct answer is B: Signs of child abuse. When a nurse observes large welts and scars on a child, it raises concern for possible child abuse. It is crucial for the nurse to assess further for signs of abuse, document findings, and report appropriately to protect the child. Choice A, history of an injury, is not specific to potential abuse and may not provide insight into the current situation. Choice C, presence of food allergies, is not directly related to the observed welts and scars. Choice D, recent recovery from chickenpox, is also unrelated to the signs of abuse and does not impact the immediate assessment of the child's safety.
3. A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client’s medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
4. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?
- A. Sit down in a chair near the client.
- B. Position self within an arm's length of the client.
- C. Ensure that there is physical space between the nurse and client.
- D. Move to a position that allows the client to be closest to the room's door.
Correct answer: C
Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.
5. An example of secondary prevention strategy would be:
- A. Screening for breast cancer in women who have no symptoms
- B. Using pain control medications for terminal cancer patients
- C. Educating teenagers about using condoms to prevent STDs
- D. None of the above
Correct answer: A
Rationale: The correct answer is A. Screening for breast cancer is a secondary prevention strategy aimed at early detection, which falls under secondary prevention as it focuses on early identification and intervention before the disease progresses. Choice B is incorrect as it refers to palliative care for symptom management in terminal cancer patients, which is not a secondary prevention strategy. Choice C is incorrect as educating teenagers about condom use is a primary prevention strategy to prevent the initial occurrence of STDs rather than intervening after exposure, making it a primary, not a secondary prevention strategy. Choice D is incorrect as there is a valid example of a secondary prevention strategy provided in choice A.