HESI LPN
HESI Practice Test for Fundamentals
1. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Dangle the patient at the bedside.
- C. Encourage isometric exercises.
- D. Suggest a high-calcium diet.
Correct answer: B
Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.
2. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?
- A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet
- B. Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses
- C. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed
- D. Document why the blood pressure cannot be accurately measured at the present time
Correct answer: D
Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.
3. A client with rheumatoid arthritis is prescribed leflunomide. What instruction should the nurse include in the client's teaching plan?
- A. Avoid alcohol while taking this medication.
- B. Take this medication with food to decrease gastrointestinal upset.
- C. Avoid sunlight while taking this medication.
- D. Report any signs of infection to the healthcare provider.
Correct answer: A
Rationale: Leflunomide can increase sensitivity to sunlight. While it is important to avoid excessive sun exposure, the critical instruction for the client is to avoid alcohol while taking this medication. Alcohol can potentiate the hepatotoxic effects of leflunomide, making it crucial for the client to abstain from alcohol consumption to prevent liver damage.
4. A client with a diagnosis of generalized anxiety disorder is prescribed sertraline. The nurse should instruct the client that this medication may have which potential side effect?
- A. Nausea
- B. Drowsiness
- C. Insomnia
- D. Headache
Correct answer: A
Rationale: The correct answer is A: Nausea. Sertraline, a selective serotonin reuptake inhibitor (SSRI), is known to commonly cause gastrointestinal side effects such as nausea. It is recommended for clients to take sertraline with food to help minimize this potential side effect. Choice B, Drowsiness, is less commonly associated with sertraline use. Insomnia, choice C, is not a typical side effect of sertraline; in fact, it may help improve sleep in some individuals. Headache, choice D, is also not a common side effect of sertraline.
5. The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?
- A. Elevated AST and ALT levels
- B. Decreased albumin level
- C. Elevated bilirubin level
- D. Prolonged PT/INR
Correct answer: D
Rationale: In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This finding indicates impaired liver function affecting the synthesis of clotting factors, leading to an increased risk of bleeding. Elevated AST and ALT levels (Choice A) indicate liver cell damage but do not directly correlate with the risk of bleeding. A decreased albumin level (Choice B) is common in liver disease but is not the most concerning in terms of bleeding risk. Elevated bilirubin levels (Choice C) are seen in liver disease but do not directly reflect the risk of bleeding as PT/INR values do.