HESI LPN
Community Health HESI Questions
1. The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct answer: B
Rationale: The client's inability to effectively clear the airway due to pain and sputum production hinders the cough mechanism, making 'Ineffective airway clearance' the most appropriate nursing diagnosis. Although impaired gas exchange may occur due to the pneumonia, the immediate issue is the inability to clear the airway. 'Ineffective breathing pattern' does not address the specific issue of airway clearance. 'Anxiety' is not the priority when the focus should be on the physical complications of pneumonia.
2. A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client’s continuity of care?
- A. Plan to assign the client a different nurse each shift
- B. Limit the number of interdisciplinary team members involved in managing the client’s care
- C. Request that the client complete a satisfaction survey at discharge
- D. Start discharge planning on the day of admission
Correct answer: D
Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.
3. Which of the following strategies can help improve patient adherence to treatment plans?
- A. Providing clear and understandable instructions
- B. Using medical jargon
- C. Limiting patient education
- D. Ignoring patient feedback
Correct answer: A
Rationale: Providing clear and understandable instructions can help improve patient adherence to treatment plans. Clear instructions help patients better understand their treatment plans, leading to increased compliance. Choices B, C, and D are incorrect. Using medical jargon can confuse patients and reduce adherence. Limiting patient education deprives patients of essential information needed for adherence. Ignoring patient feedback can lead to misunderstandings and hinder the patient's commitment to the treatment plan.
4. After surgery to correct hypertrophic pyloric stenosis (HPS) in a 3-week-old infant who had been formula-fed, which postoperative feeding order is appropriate?
- A. Thickened formula 24 hours after surgery
- B. Withholding feedings for the first 24 hours
- C. Regular formula feeding within 24 hours after surgery
- D. Additional glucose feedings as desired after the first 24 hours
Correct answer: C
Rationale: Following surgery for hypertrophic pyloric stenosis (HPS) in infants, it is appropriate to resume regular formula feeding within 24 hours postoperatively to support recovery. This helps maintain adequate nutrition and hydration for the infant. Choice A is incorrect because thickened formula may not be necessary and could potentially cause issues postoperatively. Choice B is incorrect as withholding feedings for the first 24 hours can lead to nutritional deficiencies and delay recovery. Choice D is inappropriate as additional glucose feedings are not typically indicated postoperatively for infants with HPS and may not provide the necessary nutrition needed for recovery.
5. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
- A. “The client’s age is not a factor in the measurement.”
- B. “The scale measures six elements.”
- C. “A lower score indicates a higher risk of pressure ulcers.”
- D. “Each element is scored on a range from 1 to 4 points.”
Correct answer: B
Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.