HESI LPN
HESI Fundamentals Exam
1. The client has a nasogastric (NG) tube in place for decompression. What action should the LPN/LVN take to maintain patency of the NG tube?
- A. Irrigate the tube with normal saline every shift.
- B. Check the tube placement by auscultation.
- C. Secure the tube to the client's gown.
- D. Flush the tube with 5 mL of sterile water before and after medication administration.
Correct answer: A
Rationale: To maintain patency of the NG tube, it is essential to irrigate the tube with normal saline every shift. This action helps prevent clogging and ensures that the tube remains clear for effective decompression. Checking tube placement by auscultation (Choice B) is important for verifying correct placement but does not directly impact patency. Securing the tube to the client's gown (Choice C) is crucial for safety and comfort but is not directly related to maintaining patency. Flushing the tube with sterile water before and after medication administration (Choice D) is not the recommended method for maintaining patency of an NG tube, as normal saline is the appropriate solution for this purpose.
2. When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
- A. Press gently on the tragus of the client’s ear.
- B. Pull the ear lobe up and back.
- C. Insert the medication deeply into the ear canal.
- D. Massage the ear gently after administering the medication.
Correct answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client’s ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.
3. A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?
- A. Commend the client for selecting a high biological value protein.
- B. Remind the client that protein in the diet should be avoided.
- C. Suggest that the client also select orange juice to promote absorption.
- D. Encourage the client to attend classes on dietary management of chronic renal failure.
Correct answer: A
Rationale: The correct action is to commend the client for selecting a high biological value protein, as scrambled eggs provide a good protein source for clients with chronic renal failure. Protein is essential for maintaining muscle mass and overall health in these clients. Reminding the client to avoid protein is incorrect as it may lead to protein-energy malnutrition, which is a common concern in chronic renal failure. Suggesting orange juice for absorption is not relevant to the situation, as protein absorption is not a primary concern in this context. Encouraging the client to attend classes on dietary management of chronic renal failure is important for overall education but is not the immediate action needed in response to the client's breakfast choice.
4. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?
- A. Administer oxygen via a nasal cannula.
- B. Measure the client's vital signs.
- C. Obtain a 12-lead ECG.
- D. Encourage the client to use pursed-lip breathing.
Correct answer: A
Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.
5. Under the provisions of the Americans with Disabilities Act, what are nurse managers required to do?
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct answer: B
Rationale: The correct answer is B: 'Provide reasonable accommodations for disabled individuals.' The Americans with Disabilities Act (ADA) mandates nurse managers to offer reasonable accommodations for disabled individuals to ensure equal opportunities in the workplace. Choice A is incorrect because although maintaining a hazard-free environment is essential, the focus of the ADA is on accommodations for disabled individuals. Choice C is incorrect as it overly generalizes the accommodations without specifying the need for them to be 'reasonable.' Choice D is incorrect because the ADA does not specify a requirement to consider both mental and physical disabilities; instead, it emphasizes providing reasonable accommodations regardless of the disability type.
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