HESI LPN
HESI Fundamentals Test Bank
1. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?
- A. Offer small sips of water through a straw
- B. Place tongue blade on back half of tongue
- C. Use a penlight to observe back of the oral cavity
- D. Auscultate breath sounds after the client swallows
Correct answer: B
Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.
2. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric unit. What does the nurse expect when palpating the infant’s abdomen?
- A. A distended colon
- B. Marked tenderness around the umbilicus
- C. An olive-sized mass in the right upper quadrant
- D. Rhythmic peristaltic waves in the lower abdomen
Correct answer: C
Rationale: When palpating the abdomen of an infant with hypertrophic pyloric stenosis (HPS), the nurse would expect to feel an olive-sized mass in the right upper quadrant. This finding is characteristic of HPS due to the hypertrophied pylorus muscle. Choices A, B, and D are incorrect. A distended colon is not typically associated with HPS. Marked tenderness around the umbilicus is not a specific finding of HPS. Rhythmic peristaltic waves in the lower abdomen are not expected in HPS, as the condition primarily affects the pylorus region of the stomach.
3. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?
- A. Tingling in the hands and around the mouth.
- B. Nausea and vomiting.
- C. Constipation.
- D. Bradycardia.
Correct answer: A
Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.
4. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach and phase the nurse manager should
- A. Discuss with the staff how to deal with any defensive behavior
- B. Explain to the unit staff why change is necessary
- C. Assist the staff during the acceptance of the new changes
- D. Clarify what the changes mean to the community and hospital
Correct answer: B
Rationale: The "unfreezing" phase involves preparing staff for change by explaining the necessity and benefits of the change, helping them to understand and accept it.
5. The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. Formula or breast milk
- B. Broth and tea
- C. Rice cereal and apple juice
- D. Gelatin and ginger ale
Correct answer: A
Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.