HESI LPN
Practice HESI Fundamentals Exam
1. The healthcare professional is caring for a client who is post-operative following a hip replacement. Which assessment finding would require immediate intervention?
- A. Pain at the surgical site
- B. Swelling in the affected leg
- C. Elevated temperature
- D. Shortness of breath
Correct answer: D
Rationale: Shortness of breath is a critical assessment finding that could indicate a pulmonary embolism or other serious complication related to surgery, such as a respiratory issue or cardiac problem. Immediate intervention is necessary to prevent further complications or harm to the client. Pain at the surgical site is common post-operatively and can be managed with appropriate pain relief measures. Swelling in the affected leg is expected after a hip replacement and can often be managed conservatively or monitored closely. An elevated temperature could be a sign of infection, which is important to address but may not require immediate intervention unless other symptoms of sepsis are present.
2. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client’s admitting diagnosis?
- A. Jugular vein distention.
- B. Crackles in the lung bases.
- C. Peripheral edema.
- D. Bounding peripheral pulses.
Correct answer: B
Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.
3. A client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy is receiving teaching from a healthcare provider. Which statement by the client indicates an understanding of the teaching?
- A. “I will count baby’s kicks every other day.”
- B. “I will alternate the arm used to check my blood pressure.”
- C. “I will consume 50 grams of protein daily.”
- D. ---
Correct answer: B
Rationale: The correct answer is B. Alternating arms for blood pressure checks ensures more accurate readings and helps monitor preeclampsia. Option A, counting baby's kicks every other day, is not specific to managing preeclampsia. Option C, consuming 50 grams of protein daily, is important for a healthy diet during pregnancy but does not directly relate to preeclampsia management.
4. What is the primary nursing intervention that the practical nurse should perform before administering ampicillin to a client diagnosed with a urinary tract infection?
- A. Obtain a clean-catch urine specimen.
- B. Assess the urine pH for acidity.
- C. Insert an indwelling catheter.
- D. Assess for complaints of dysuria.
Correct answer: A
Rationale: The correct answer is to obtain a clean-catch urine specimen. Before administering ampicillin to a client with a urinary tract infection, it is crucial to collect a urine specimen to determine the causative organism and evaluate the effectiveness of pharmacological therapy. Assessing the urine pH for acidity (choice B) is not the primary intervention needed before administering ampicillin. Inserting an indwelling catheter (choice C) is invasive and not necessary unless indicated for specific reasons. Assessing for complaints of dysuria (choice D) is important but does not take precedence over obtaining a urine specimen for proper diagnosis and treatment.
5. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to
- A. Give the client orientation materials and review the unit rules and regulations
- B. Introduce oneself and accompany the client to their room
- C. Take the client to the day room and introduce them to the other clients
- D. Ask the nursing assistant to get the client’s vital signs and complete the admission search
Correct answer: B
Rationale: In situations where a client is trembling and fearful upon admission to a psychiatric unit, it is essential to prioritize building trust and reducing anxiety. By introducing oneself and accompanying the client to their room, the nurse can establish a therapeutic relationship, provide a sense of security, and address the client's immediate emotional needs. Choices A, C, and D are not the most appropriate initial responses as they do not directly address the client's emotional state or focus on establishing a supportive relationship.