HESI LPN
Fundamentals HESI
1. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
- A. Roof of mouth, gums, and inside cheeks
- B. Chewing and inner tooth surfaces
- C. Outer tooth surfaces
- D. Tongue
Correct answer: C
Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.
2. A client with difficulty self-feeding due to rheumatoid arthritis should be referred to which member of the interprofessional care team to use adaptive devices?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct answer: D
Rationale: The correct answer is D, Occupational therapist. Occupational therapists specialize in assisting clients with adaptive devices to enhance their ability to perform daily activities like self-feeding. They evaluate client needs and provide interventions to promote independence in activities of daily living. Choice A, Social worker, focuses on psychosocial support and community resources, not directly addressing the physical aspect of self-feeding difficulty. Choice B, Certified nursing assistant, is involved in direct patient care but lacks specialized training in adaptive devices. Choice C, Registered dietitian, primarily focuses on nutrition-related issues and may not have the expertise in adaptive devices and functional rehabilitation necessary for this client's self-feeding challenges.
3. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
- A. HR 105/min
- B. BMI 25 kg/m²
- C. BP 148/92
- D. Glucose 45 mg/dL
Correct answer: D
Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.
4. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?
- A. Potassium 5.4
- B. Sodium 140
- C. Calcium 8.6
- D. Magnesium 2.0
Correct answer: A
Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.
5. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?
- A. A patient who is afebrile
- B. A patient who is diaphoretic
- C. A patient with strong pedal pulses
- D. A patient with adequate skin turgor
Correct answer: B
Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.
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