HESI LPN
Community Health HESI Test Bank
1. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day is the most effective in removing respiratory secretions in a client with pneumococcal pneumonia. Adequate hydration helps thin secretions, making them easier to expectorate. Administration of cough suppressants (Choice A) may hinder the removal of secretions by suppressing the cough reflex. Maintaining bed rest with bathroom privileges (Choice C) is important but does not directly address the removal of respiratory secretions. Performing chest physiotherapy (Choice D) is beneficial for mobilizing secretions but may not be as effective as increasing fluid intake in thinning and facilitating the removal of secretions.
2. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?
- A. Omit the section of the assessment form
- B. Ask her if she would like an interpreter to help her understand the question
- C. Reword the question to make it more culturally sensitive
- D. Observe the client's response when asked a different question
Correct answer: D
Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.
3. At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement?
- A. Administer insulin based on the sliding scale
- B. Assess the appearance of the foot wound
- C. Obtain antibiotic peak and trough levels
- D. Initiate hourly measurements of urine output
Correct answer: B
Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.
4. Which of the following is considered a micronutrient?
- A. Protein
- B. Carbohydrate
- C. Vitamin C
- D. Fat
Correct answer: C
Rationale: Corrected Question: Vitamin C is considered a micronutrient because it is required in small amounts for proper body functioning and is essential for health. Proteins, carbohydrates, and fats are macronutrients, needed in larger quantities for energy and other body functions. Vitamin C, being a micronutrient, plays a crucial role in various bodily functions even though it is needed in smaller quantities compared to macronutrients. Therefore, the correct answer is C. Choice A (Protein), Choice B (Carbohydrate), and Choice D (Fat) are incorrect as they are macronutrients required in larger amounts for energy and other body functions.
5. A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, putting the child at a higher risk of developing infections. Early detection of signs of infection is crucial to prevent serious complications and initiate timely treatment. Providing nutritional support is important for overall health but is not the priority when the child is at risk of infection. Monitoring for signs of bleeding is essential, but infection surveillance takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of pain is important for comfort but is not the priority over infection prevention and management.