HESI LPN
HESI Fundamental Practice Exam
1. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?
- A. I will need to change the colostomy bag every day.
- B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
- C. I need to empty the colostomy bag when it is one-third to one-half full.
- D. I will need to take care of the skin around the stoma to prevent irritation.
Correct answer: A
Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.
2. Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?
- A. Determine the reason why the client is refusing to use the incentive spirometer.
- B. Insist that the client use the incentive spirometer.
- C. Administer pain medication to help the client use the spirometer.
- D. Document the refusal in the client’s medical record.
Correct answer: A
Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.
3. The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
- A. Infant will experience minimal pain
- B. Muscle spasms will be relieved
- C. Mobility will be managed as tolerated
- D. Tissue perfusion will be maintained
Correct answer: D
Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.
4. The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?
- A. Most childhood cancers affect tissues rather than organs.
- B. Childhood cancers are usually localized when found.
- C. Unlike adult cancers, childhood cancers are less responsive to treatment.
- D. The majority of childhood cancers can be prevented.
Correct answer: A
Rationale: The correct answer is A. Most childhood cancers, such as leukemias and sarcomas, affect tissues rather than specific organs, unlike many adult cancers. Choice B is incorrect because childhood cancers can be localized or spread, similar to adult cancers. Choice C is incorrect because childhood cancers can be highly responsive to treatment, especially when diagnosed early. Choice D is incorrect because the majority of childhood cancers cannot be prevented as they are often due to genetic mutations or unknown causes.
5. The nurse is providing preoperative teaching to a client who will undergo a thyroidectomy. What information should the nurse include about postoperative care?
- A. Importance of maintaining neck stability
- B. How to care for the surgical drain
- C. Pain management strategies
- D. All of the above
Correct answer: D
Rationale: Providing preoperative teaching for a client undergoing a thyroidectomy is essential to prepare them for postoperative care. Information about the importance of maintaining neck stability is crucial to prevent complications such as strain on the surgical site. Teaching the client how to care for the surgical drain is important to prevent infections, ensure proper wound healing, and aid in monitoring postoperative recovery. Pain management strategies are vital to ensure the client's comfort and promote optimal recovery. Including all these aspects in preoperative teaching ensures the client is well-prepared for comprehensive postoperative care. Therefore, the correct answer is D because all these elements are essential components of postoperative care for a client undergoing a thyroidectomy. Choices A, B, and C are all important aspects of postoperative care that the nurse should include in the preoperative teaching session.