HESI LPN
Community Health HESI Exam
1. The RN is making a home visit to a female client with end-stage heart disease. She has a living will and states she will never go back to the hospital. During the visit, the RN notes that the client is pale and SOB while speaking. The RN discovers 3+ edema in both ankles and bilateral pulmonary crackles. Which intervention should the RN implement first?
- A. Order a chest X-ray
- B. Obtain a peripheral O2 saturation reading
- C. Obtain an order for complete blood count
- D. Tell the patient to stay in bed
Correct answer: B
Rationale: Obtaining a peripheral O2 saturation reading is the priority intervention in this scenario. It helps assess the client's oxygenation status quickly, which is crucial in a client with signs of respiratory distress, such as shortness of breath and bilateral pulmonary crackles. Ordering a chest X-ray (Choice A) may be necessary later but does not address the immediate need for oxygen assessment. Obtaining an order for a complete blood count (Choice C) is not the priority in this situation as it does not directly address the client's respiratory distress. Instructing the patient to stay in bed (Choice D) does not address the underlying issue of potential hypoxia and respiratory compromise.
2. A client with a diagnosis of generalized anxiety disorder is prescribed lorazepam. The client should be informed that this medication may have which potential side effect?
- A. Drowsiness
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: The correct answer is A: Drowsiness. Lorazepam, a medication commonly used to treat anxiety disorders, can lead to drowsiness as a common side effect. It is important for clients to be aware of this potential effect, and they should be advised to avoid activities like driving until they understand how the medication affects them. Dry mouth, nausea, and headache are possible side effects of other medications but are less commonly associated with lorazepam.
3. A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. You should contact the provider about your wishes for your family member.
- B. We'll need to have the nursing supervisor review the client's advance directives.
- C. You should speak with the facility's ethics committee about your concerns.
- D. As the health care surrogate, the client's partner can make this decision.
Correct answer: D
Rationale: The correct response is D because the health care surrogate, as designated by the client, has the legal authority to make healthcare decisions on behalf of the client when they are unable to do so. This authority includes decisions about treatment continuation or withdrawal. Option A is incorrect as the family member's wishes do not override the legal authority of the health care surrogate. Option B is not the most appropriate action in this situation as the advance directives are already clear by the designation of a health care surrogate. Option C is not necessary at this stage since the health care surrogate can make the decision without involving the ethics committee.
4. What is the most important aspect of colostomy care to teach the client?
- A. Change the colostomy bag only when necessary
- B. Eat a low-residue diet
- C. Assess the stoma for color and swelling
- D. Irrigate the colostomy only if advised by a healthcare provider
Correct answer: C
Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.
5. A child is being assessed for suspected intussusception. What clinical manifestation is the healthcare provider likely to observe?
- A. Projectile vomiting
- B. Currant jelly stools
- C. Abdominal distension
- D. Constipation
Correct answer: C
Rationale: The correct clinical manifestation the healthcare provider is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception involves one portion of the intestine telescoping into another, causing obstruction. Abdominal distension is a common symptom due to the obstruction and buildup of gas and fluid in the affected area. While projectile vomiting can occur, it is not as specific to intussusception as abdominal distension. Currant jelly stools, which are stools containing blood and mucus, are a classic sign of intussusception but are not a clinical manifestation observable on assessment. Constipation is not typically associated with intussusception, as this condition often presents with symptoms of bowel obstruction rather than constipation.