HESI LPN
HESI Fundamentals Test Bank
1. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?
- A. Administer antibiotic therapy for 10 days
- B. Teach the client isometric exercises for legs
- C. Assess movement and sensation of extremities
- D. Assist the client to stand up at the bedside within the first 24 hours
Correct answer: C
Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.
2. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
- A. Evaluate electrolytes
- B. Restrict fluid intake
- C. Administer diuretics
- D. Monitor vital signs
Correct answer: A
Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.
3. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?
- A. Chamomile
- B. Ginseng
- C. Ginger
- D. Echinacea
Correct answer: A
Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.
4. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?
- A. Knee picture
- B. Ankle picture
- C. Elbow picture
- D. Wrist picture
Correct answer: A
Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.
5. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.
- A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
- B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
- C.
- D.
Correct answer: B
Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.
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