HESI LPN
HESI Fundamentals Test Bank
1. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
2. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?
- A. Administer antihypertensives as prescribed.
- B. Check the client’s weight daily.
- C. Notify the provider if the urine output is less than 30 mL/hr.
- D. Encourage the client to ambulate independently four times a day.
Correct answer: B
Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.
3. During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?
- A. Orient the client to their room.
- B. Conduct a client care conference.
- C. Review medical prescriptions.
- D. Develop a plan of care.
Correct answer: A
Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.
4. A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
- A. Reposition the client
- B. Document the client's IV intake in the medical record
- C. Request a new IV fluid prescription
- D. Check the IV tubing for obstruction
Correct answer: D
Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.
5. Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?
- A. Encourage them to express their concerns.
- B. Discourage them from talking about their baby.
- C. Assure them not to worry because the anomaly can be repaired.
- D. Show them postoperative photographs of infants who had a similar anomaly.
Correct answer: A
Rationale: Encouraging parents to express their concerns is the most supportive intervention as it allows them to process their emotions and provides an opportunity for the nurse to offer appropriate support and information. This choice focuses on validating the parents' feelings and creating an open communication channel. Choices B and C are incorrect as they can hinder the parents' emotional processing and may provide false reassurance. Choice D, showing postoperative photographs, may not be appropriate at this stage as it might not address the parents' current emotional needs and could induce anxiety or unrealistic expectations.