HESI LPN
HESI Fundamentals Exam
1. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?
- A. Arm
- B. Hip
- C. Back
- D. Ankle
Correct answer: C
Rationale: The correct answer is C: Back. Back injuries are common among healthcare workers, especially nurses, due to improper lifting techniques and bending. Working on an orthopedic rehabilitation unit involves frequent lifting and positioning of patients, putting the nurse at risk of back injuries. Preventing back injuries is crucial for maintaining the nurse's health and ability to provide care effectively. Choices A, B, and D are incorrect because while lifting and positioning patients may involve these body parts, back injuries are most likely to occur due to the strain and stress placed on the back during such activities.
2. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
3. A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
- A. Compare prescriptions with medications the client received during hospitalization.
- B. Only review the client’s current medications.
- C. Provide a list of medications without checking for interactions.
- D. Discuss the client’s medication history without verification.
Correct answer: A
Rationale: The correct answer is A: Compare prescriptions with medications the client received during hospitalization. This step is crucial in ensuring the accuracy of medication reconciliation. By comparing the current prescriptions with the medications administered during the hospital stay, the nurse can identify any discrepancies, omissions, or duplications in the medications. This comprehensive comparison helps prevent medication errors and ensures that the client's home medications align with the treatment received in the hospital. Choice B is incorrect because solely reviewing the client's current medications may overlook important changes or additions made during the hospitalization. Choice C is incorrect as providing a list of medications without checking for interactions can lead to potential adverse effects or drug interactions. Choice D is incorrect as discussing the client's medication history without verification may not provide an accurate representation of the medications the client actually received during the hospital stay.
4. A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?
- A. Side-lying
- B. Supine
- C. Semi-Fowler’s
- D. Trendelenburg
Correct answer: C
Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler’s position. Placing the client in Semi-Fowler’s or high-Fowler’s position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.
5. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?
- A. Allowing the client to function independently will strengthen muscles and promote healing.
- B. The client needs privacy at times for self-reflection and organizing life.
- C. The client’s sense of loss can be lessened through retaining control of some areas of life.
- D. Performing ADLs is a requirement prior to discharge from an acute care facility.
Correct answer: C
Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.
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