HESI LPN
HESI Fundamentals Exam Test Bank
1. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?
- A. Hypertension
- B. Bradycardia
- C. Hypoglycemia
- D. Weight gain
Correct answer: A
Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.
2. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?
- A. Lock the wheels on both the bed and stretcher
- B. Adjust the bed to a low position
- C. Ask the client to assist in the transfer
- D. Use a transfer sheet without locking the wheels
Correct answer: A
Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.
3. What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?
- A. Remove the basin of water from the client's bed immediately
- B. Remind the UAP to dry between the client's toes completely
- C. Advise the UAP that this procedure may damage the skin
- D. Add skin cream to the basin of water while the foot is soaking
Correct answer: A
Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.
4. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?
- A. Firmly tell the client not to grab
- B. Redirect the client’s attention
- C. Use physical restraints
- D. Avoid contact with the client
Correct answer: B
Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.
5. A healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)
- A. Develop an acceptance of diminished strength and increased dependence on others.
- B. Spend time focusing on improving job performance.
- C. Welcome opportunities to be creative and productive.
- D. Commit to finding friendship and companionship.
Correct answer: A
Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.
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