HESI LPN
HESI Fundamentals Exam Test Bank
1. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?
- A. Wheezing
- B. Shortness of breath
- C. Use of accessory muscles
- D. Cough with sputum production
Correct answer: C
Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.
2. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. “I will take a hot bath before going to bed.”
- B. “I will take my new medication in the evening.”
- C. “I will leave a light on in my bathroom at night.”
- D. “I will weigh myself once weekly.”
Correct answer: C
Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.
3. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?
- A. The client's stronger side holds the cane
- B. The top of the cane is parallel to the client's waist
- C. The client holds the cane on the stronger side of their body
- D. The client moves the cane 46 cm (18 in) forward
Correct answer: C
Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.
4. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed.
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client’s blood pressure and pulse deficit
Correct answer: D
Rationale: Checking the client’s blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.
5. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
- A. Use the planning step of the nursing process to prioritize client care delivery.
- B. Delegate all tasks to assistive personnel.
- C. Focus on completing tasks in the order they are assigned.
- D. Avoid using a checklist for daily tasks.
Correct answer: A
Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.
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