HESI LPN
HESI Fundamentals Exam Test Bank
1. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?
- A. Place the pillow under the patient's head and shoulders.
- B. Attempt to do it alone if the bed is in a flat position.
- C. Place the side rails in the up position.
- D. Use a friction-reducing device.
Correct answer: D
Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.
2. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)
- A. “The temperature around the IV site is cooler.”
- B. “The rate of the infusion increases.”
- C. “The skin at the IV site is red.”
- D. “The IV dressing is damp.”
Correct answer: A
Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.
3. A client is admitted with acute pyelonephritis. Which symptom should the nurse expect the client to report?
- A. Flank pain
- B. Pedal edema
- C. Hypotension
- D. Weight gain
Correct answer: A
Rationale: Flank pain is a classic symptom of acute pyelonephritis, which is a bacterial infection of the kidney. It occurs due to inflammation and irritation of the renal capsule, leading to pain in the flank region. Pedal edema (swelling in the feet and ankles) is more commonly associated with conditions like heart failure or kidney disease, not typically seen in acute pyelonephritis. Hypotension (low blood pressure) is a systemic symptom that may occur with severe infections but is not a specific hallmark of pyelonephritis. Weight gain is also not a typical symptom of acute pyelonephritis; instead, patients may experience weight loss due to decreased appetite and systemic effects of infection.
4. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?
- A. Encourage the client to relax and take deep breaths during the dressing change.
- B. Educate the client about the importance of pain management postoperatively.
- C. Assist the client to a comfortable position for the dressing change.
- D. Administer pain medication 45 minutes before changing the client's dressing.
Correct answer: D
Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.
5. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?
- A. Hypertension
- B. Bradycardia
- C. Hypoglycemia
- D. Weight gain
Correct answer: A
Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.
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