HESI LPN
Community Health HESI Practice Exam
1. The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
- A. Trendelenburg
- B. Prone
- C. Semi-Fowler's
- D. Side-lying with head flat
Correct answer: C
Rationale: The correct answer is C, Semi-Fowler's. This position helps to reduce intracranial pressure by promoting venous drainage from the head while maintaining adequate oxygenation. Option A, Trendelenburg position, is incorrect as it involves placing the patient with the head lower than the body, which can increase intracranial pressure. Option B, Prone position, is also incorrect as it involves lying on the stomach, which can further elevate intracranial pressure. Option D, Side-lying with head flat, does not provide the same benefits as the Semi-Fowler's position in terms of promoting venous drainage and maintaining oxygenation in a client with increased intracranial pressure.
2. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?
- A. A 38-week primigravida who reports contractions occurring every 10 minutes
- B. A 39-week primigravida with a biophysical profile score of 5 out of 8
- C. A 41-week multigravida who is scheduled for induction of labor today
- D. A 36-week multigravida with a prescription for serial blood pressure
Correct answer: B
Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.
3. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
- A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
- B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
- C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
- D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.
Correct answer: C
Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.
4. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?
- A. Discuss treatment options for abusive partners.
- B. Explore the client's readiness to discuss the situation.
- C. Determine the frequency and type of client's abuse.
- D. Report the finding to the police department.
Correct answer: B
Rationale: Exploring the client's readiness to discuss the situation is the correct first step. It allows the nurse to assess the client's emotional state, willingness to seek help, and readiness to address the abusive relationship. This approach helps build trust and rapport with the client, paving the way for further interventions. Discussing treatment options for abusive partners (Choice A) may be premature and not well-received if the client is not ready to address the situation. Determining the frequency and type of abuse (Choice C) is important but not the immediate priority compared to assessing the client's readiness to talk. Reporting the finding to the police (Choice D) should be done if there is an immediate threat to the client's safety, but exploring the client's readiness to discuss the situation should be the initial step to provide support and intervention.
5. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?
- A. Perform a bladder scan to assess for urinary retention.
- B. Encourage the client to drink fluids.
- C. Insert a straight catheter to drain the bladder.
- D. Administer a diuretic as prescribed.
Correct answer: A
Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.