HESI LPN
HESI Fundamentals Exam Test Bank
1. What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?
- A. Encourage the client to use an incentive spirometer regularly.
- B. Assist the client in ambulating as soon as possible.
- C. Position the client in high Fowler's position.
- D. Encourage the client to cough and deep breathe regularly.
Correct answer: A
Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.
2. When using an open irrigation technique for a client's catheter, what action should the nurse take?
- A. Subtract the amount of irrigant used from the client's urine output.
- B. Add the amount of irrigant used to the urine output measurement.
- C. Measure the amount of irrigant used separately from the urine output.
- D. Document the total amount of fluid used for irrigation only.
Correct answer: A
Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.
3. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN?
- A. Creating a plan of care for a client who is recovering following a stroke.
- B. Assessing a pressure injury on a client who is on bed rest.
- C. Providing nasopharyngeal suctioning for a client who has pneumonia.
- D. Teaching a client who has asthma to use a metered-dose inhaler.
Correct answer: C
Rationale: The correct answer is providing nasopharyngeal suctioning for a client who has pneumonia. This task falls within the practical nurse's scope of practice, as it involves direct patient care and basic interventions. Creating a plan of care for a client recovering from a stroke involves critical thinking and comprehensive assessment, which are typically responsibilities of registered nurses. Assessing a pressure injury requires specialized wound care knowledge, often performed by wound care specialists or registered nurses with wound care training. Teaching a client to use a metered-dose inhaler involves patient education and requires a thorough understanding of asthma management, making it more suitable for a registered nurse.
4. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?
- A. “My baby loved to play with the crib gym, but I took it out of the crib.”
- B. “I just bought a firm mattress so my baby will sleep better.”
- C. “My baby really likes sleeping on the fluffy pillow we just got.”
- D. “I put the baby’s car seat on the table after I put him in it.”
Correct answer: A
Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.
5. A healthcare provider is receiving a prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the healthcare provider clarify?
- A. Dietitian consult
- B. Speech therapy referral
- C. Oral suction at the bedside
- D. Clear liquids
Correct answer: D
Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at high risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids. Therefore, the healthcare provider should clarify the prescription for clear liquids and consider recommending thickened liquids instead to reduce the risk of aspiration. Choice A, 'Dietitian consult,' is essential to ensure the client receives appropriate nutrition tailored to their condition. Choice B, 'Speech therapy referral,' is crucial for dysphagia management and rehabilitation. Choice C, 'Oral suction at the bedside,' is a standard intervention to maintain airway patency and is not contraindicated in clients with dysphagia.
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