HESI LPN
HESI Fundamental Practice Exam
1. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?
- A. Check the placement of the tube by auscultation.
- B. Flush the tube with 30 ml of water before and after medication administration.
- C. Administer the medication with food to prevent nausea.
- D. Dilute the medication with normal saline before administration.
Correct answer: B
Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.
2. A client with a history of atrial fibrillation is prescribed apixaban. The nurse should monitor for which potential side effect?
- A. Bleeding
- B. Weight gain
- C. Headache
- D. Nausea
Correct answer: A
Rationale: The correct answer is A: Bleeding. Apixaban is an anticoagulant medication that works by decreasing the blood's ability to clot. One of the significant side effects of apixaban is an increased risk of bleeding. Therefore, the nurse should monitor the client for signs of bleeding, such as easy bruising, prolonged bleeding from cuts, blood in the urine or stool, or unusual bleeding or bruising. Monitoring for these signs is crucial to prevent or manage any potential complications associated with the medication. Choices B, C, and D are incorrect because weight gain, headache, and nausea are not typically associated with apixaban use. Therefore, the nurse should primarily focus on monitoring for signs of bleeding in a client prescribed apixaban.
3. A 19-year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of 'suppression'?
- A. "I don't remember anything about what happened to me."
- B. "I'd rather not talk about it right now."
- C. "It's all the other guy's fault! He was going too fast."
- D. "My mother is heartbroken about this."
Correct answer: B
Rationale: The correct answer is B because the statement "I'd rather not talk about it right now" indicates that the client is consciously choosing to avoid discussing the distressing issue, which aligns with the mechanism of suppression. Choice A does not involve active avoidance but rather memory loss, which is not suppression. Choice C involves blaming others, which is a defense mechanism known as projection. Choice D involves expressing emotions rather than avoiding them, which does not align with suppression.
4. A client with a history of alcohol dependence tells the nurse that he has been sober for three months but has recently started drinking again. What should the nurse do next?
- A. Ask the client why he started drinking again.
- B. Provide information about support groups for sobriety.
- C. Discuss the consequences of drinking on his health.
- D. Encourage the client to express his feelings about relapse.
Correct answer: D
Rationale: Encouraging the client to express his feelings about relapse is the most appropriate action for the nurse to take in this situation. This approach allows the nurse to address the underlying emotions and factors contributing to the relapse. Choice A, asking the client why he started drinking again, may come across as judgmental and might not be as effective in exploring the client's emotions. Choice B, providing information about support groups, is important but should come after addressing the client's current emotional state. Choice C, discussing the consequences of drinking, may be necessary at some point, but initially, the focus should be on the client's feelings and emotions surrounding the relapse.
5. The healthcare provider is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the healthcare provider use to help prevent injury secondary to this rotation?
- A. Hand rolls
- B. A trapeze bar
- C. A trochanter roll
- D. Hand-wrist splints
Correct answer: C
Rationale: A trochanter roll is the correct choice as it is used to prevent external rotation of the hips when the patient is in a supine position. Hand rolls (Choice A) are incorrect because they are used to prevent contractures of the fingers, wrist, and hand. A trapeze bar (Choice B) is not the correct option as it helps patients change positions in bed and aids with movement, not specifically for hip rotation. Hand-wrist splints (Choice D) are also incorrect as they are used to maintain the functional position of the wrist and hand, not to address hip rotation.