HESI LPN
HESI Fundamentals Test Bank
1. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?
- A. Corn pads are an adequate treatment and should be continued.
- B. The patient should avoid soaking the feet before using a pumice stone.
- C. The current self-treatment is likely impeding circulation to the toes.
- D. Tighter shoes would help compress the corns and make them smaller.
Correct answer: C
Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.
2. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
- A. Dyspnea
- B. Heart murmur
- C. Macular rash
- D. Hemorrhage
Correct answer: B
Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.
3. Which toy is most appropriate for an 18-month-old child?
- A. A pull toy
- B. A puzzle with large pieces
- C. A book with large pictures
- D. A doll with small clothes
Correct answer: A
Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.
4. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?
- A. Obtain the blood pressure under the same conditions each time
- B. Use a different arm for each measurement
- C. Measure the blood pressure while the client is standing
- D. Take multiple readings at different times of the day
Correct answer: A
Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.
5. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
- A. Erythema along the path of the vein
- B. Pitting edema at the insertion site
- C. Coolness of the client’s left forearm
- D. Pallor of the client’s left forearm
Correct answer: A
Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.
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