HESI LPN
HESI Fundamentals Practice Questions
1. When assessing the respiratory system for complications of immobility, what action should the nurse take?
- A. Inspect chest wall movements primarily during the expiratory cycle.
- B. Auscultate the entire lung region to assess lung sounds.
- C. Focus auscultation on the upper lung fields.
- D. Assess the patient at least every 4 hours.
Correct answer: B
Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.
2. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
3. A 16-year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
- A. Progressive failure to adapt
- B. Feelings of anger or hostility
- C. Reunion wish or fantasy
- D. Feelings of alienation or isolation
Correct answer: D
Rationale: Feelings of alienation or isolation are common triggers for suicidal behavior in adolescents. This sense of being disconnected or isolated from others can lead to despair and hopelessness, increasing the risk of suicidal ideation. Choices A, B, and C are less commonly associated with suicide in adolescents. Progressive failure to adapt may contribute to stress, but it is not typically the primary cause of suicide. Feelings of anger or hostility, while negative emotions, do not always lead to suicidal behavior in adolescents. Reunion wish or fantasy is not a recognized primary cause of suicide in this age group.
4. The healthcare professional is caring for a patient with a new order for an oral laxative. Which is a contraindication in administering an oral laxative?
- A. Cardiac problems
- B. Abdominal pain of unknown origin
- C. Several hemorrhoids
- D. Chronic constipation
Correct answer: B
Rationale: Administering an oral laxative to a patient with abdominal pain of unknown origin is contraindicated because it could be a sign of a more serious underlying condition that needs immediate medical evaluation. Giving a laxative in such a situation without proper diagnosis could potentially worsen the patient's condition or delay appropriate treatment. Choice A (Cardiac problems) is not a contraindication for an oral laxative unless the patient has a specific cardiac condition that interacts with the laxative. Choice C (Several hemorrhoids) and Choice D (Chronic constipation) are not contraindications for administering an oral laxative.
5. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?
- A. Describe feelings about taking daily medications
- B. Take medications in the presence of the nurse
- C. Notify the nurse after self-medication is completed
- D. Keep a daily record of all medications taken
Correct answer: B
Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.