HESI LPN
Fundamentals HESI
1. The healthcare professional is assessing a client with a history of rheumatoid arthritis. Which of the following assessment findings would be most concerning?
- A. Morning stiffness
- B. Joint deformities
- C. Fever
- D. Weight loss
Correct answer: C
Rationale: In a client with rheumatoid arthritis, the presence of fever is most concerning because it may indicate an infection or systemic involvement, necessitating immediate attention. Morning stiffness and joint deformities are common manifestations of rheumatoid arthritis itself and are expected findings in these clients. Weight loss can occur in rheumatoid arthritis due to various factors such as decreased appetite or systemic inflammation, but it is not as acutely concerning as fever, which may signal a more urgent issue.
2. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?
- A. “I will set my water heater at 130°F.”
- B. “Once my baby can sit up, they should be safe in the bathtub.”
- C. “I will place my baby on their stomach to sleep.”
- D. “Once my infant starts to push up, I will remove the mobile from over the crib.”
Correct answer: D
Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.
3. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching?
- A. I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.
- B. MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.
- C. I will protect others from exposure when I transport the client outside the room.
- D. To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.
Correct answer: C
Rationale: The correct answer is C. Protecting others from exposure when transporting a client with MRSA is crucial in preventing the spread of infection. This statement demonstrates understanding of infection control measures. Stating that MRSA is usually resistant to vancomycin (choice B) is incorrect; vancomycin is often effective against MRSA. Obtaining a specimen for culture and sensitivity after the first dose of an antimicrobial (choice A) is unnecessary and not indicated. Discontinuing antimicrobial therapy when the client is no longer febrile (choice D) is incorrect because antimicrobial therapy should be completed as prescribed to prevent the development of resistant strains.
4. When working with a client who does not speak the same language as the nurse and an interpreter is present, which of the following actions should the nurse take?
- A. Talk directly to the client, instead of the interpreter, when speaking.
- B. Speak loudly to the interpreter.
- C. Use gestures to communicate with the client.
- D. Avoid using an interpreter and rely on family members.
Correct answer: A
Rationale: When caring for a client who speaks a different language, it is essential to communicate through an interpreter. Talking directly to the client, rather than the interpreter, ensures clear and respectful interaction. Speaking loudly to the interpreter (choice B) is not necessary and may be perceived as disrespectful. Using gestures (choice C) alone may lead to misunderstandings or misinterpretations. Avoiding the use of an interpreter and relying solely on family members (choice D) can compromise the accuracy and confidentiality of the communication.
5. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?
- A. 'All of this equipment can be frightening.'
- B. 'The equipment is necessary to monitor your condition.'
- C. 'You should try to ignore the equipment.'
- D. 'Try to relax; the equipment is not harmful.'
Correct answer: A
Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.
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