HESI LPN
Fundamentals HESI
1. The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?
- A. Apply a hydrocolloid dressing to the ulcer.
- B. Reposition the client every 2 hours.
- C. Use a donut-shaped cushion when the client is sitting.
- D. Massage the area around the ulcer to promote circulation.
Correct answer: B
Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.
2. Select the tactile sensation that is accurately paired with its description or procedure for testing.
- A. Fine motor coordination: The use of the fingers
- B. Stereognosis: Equal hearing in both ears
- C. Two-point discrimination: The nurse gently pricks the patient's skin
- D. Gross motor function: The use of the lower limbs
Correct answer: C
Rationale: The correct answer is C: Two-point discrimination: The nurse gently pricks the patient's skin. Two-point discrimination assesses the ability to discern two points touched simultaneously on the skin. Fine motor coordination (Choice A) refers to the precise movements of small muscles, not related to tactile sensation. Stereognosis (Choice B) is the ability to recognize objects by touch, not equal hearing in both ears. Gross motor function (Choice D) involves the coordination of large muscle groups, not specifically related to tactile sensation testing.
3. Which client’s vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?
- A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
- B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
- C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
- D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.
Correct answer: C
Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.
4. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client’s weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
5. What is a priority action for the nurse when caring for a client with suspected meningitis?
- A. Isolate the client in a private room
- B. Administer intravenous antibiotics
- C. Obtain a throat culture
- D. Perform a chest x-ray
Correct answer: B
Rationale: Administering intravenous antibiotics is the priority when caring for a client with suspected meningitis. The prompt administration of antibiotics is crucial to treat bacterial meningitis and prevent potential complications. Isolating the client in a private room may be necessary to prevent the spread of infection, but antibiotic administration takes precedence. Obtaining a throat culture and performing a chest x-ray are important diagnostic measures, but they do not address the immediate need for antibiotic therapy in suspected bacterial meningitis.