HESI LPN
Fundamentals of Nursing HESI
1. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Administer the medication with food to prevent nausea.
- C. Verify tube placement by aspirating stomach contents.
- D. Dilute the medication with normal saline before administration.
Correct answer: A
Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.
2. A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?
- A. Extinguish the fire.
- B. Activate the fire alarm.
- C. Move clients who are nearby.
- D. Close all open doors on the unit.
Correct answer: B
Rationale: In a fire emergency, the nurse's priority is to activate the fire alarm. This action alerts others to the emergency, initiates the evacuation process, and ensures everyone's safety. Extinguishing the fire can be dangerous and should be left to trained personnel. Moving clients who are nearby might delay the activation of the alarm and can put the nurse and clients at risk. Closing all open doors on the unit is important to contain the fire but should not take precedence over alerting others through the fire alarm system.
3. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?
- A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
- B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
- C. The arms should be crossed over the chest or in the lap.
- D. The feet should be close together with toes pointed out.
Correct answer: A
Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.
4. How should hydration status be assessed in a child with vomiting and diarrhea?
- A. Check skin turgor and mucous membranes
- B. Measure blood glucose levels
- C. Assess heart rate and blood pressure
- D. Evaluate bowel sounds
Correct answer: A
Rationale: Checking skin turgor and mucous membranes is the appropriate method to assess hydration status in a child with vomiting and diarrhea. Skin turgor is an indicator of skin elasticity, which decreases when an individual is dehydrated. Mucous membranes, such as the inside of the mouth, can also show signs of dehydration like dryness. Measuring blood glucose levels (choice B) is not relevant to assessing hydration status in this scenario. Assessing heart rate and blood pressure (choice C) is important in evaluating the overall condition of a child but may not directly indicate hydration status. Evaluating bowel sounds (choice D) is more related to assessing gastrointestinal function rather than hydration status.
5. A client with a history of myocardial infarction (MI) is receiving a beta-blocker medication. What is the most important outcome for the nurse to monitor?
- A. Heart rate and blood pressure
- B. Blood glucose levels
- C. Respiratory rate
- D. Liver function tests
Correct answer: A
Rationale: The correct answer is A: Heart rate and blood pressure. When a client with a history of myocardial infarction (MI) is on a beta-blocker medication, monitoring heart rate and blood pressure is crucial. Beta-blockers lower heart rate and blood pressure, so monitoring these parameters helps assess the medication's effectiveness and prevent complications like bradycardia or hypotension. Choices B, C, and D are not the most important outcomes to monitor in this scenario. Blood glucose levels are typically monitored in clients with diabetes or when using medications that affect glucose levels. Respiratory rate is important in assessing respiratory function and oxygenation, while liver function tests are more relevant when monitoring the impact of medications on liver health.