HESI LPN
HESI Fundamentals Exam Test Bank
1. To use the nursing process correctly, what must the nurse do first?
- A. Obtain information about the client
- B. Develop a care plan
- C. Implement interventions
- D. Evaluate the client's outcomes
Correct answer: A
Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.
2. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?
- A. 100% oxygen via partial rebreathing mask
- B. 2 liters per minute via nasal cannula
- C. 4 liters per minute via simple mask
- D. 6 liters per minute via face mask
Correct answer: A
Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.
3. A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?
- A. Maintain the airway
- B. Administer epinephrine 1:1000 as ordered
- C. Monitor for hypotension with shock
- D. Administer diphenhydramine as ordered
Correct answer: B
Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.
4. A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?
- A. “I will be sure to remove my hearing aid before taking a shower.”
- B. “I will keep my hearing aid in at all times, even when sleeping.”
- C. “I will clean my hearing aid with alcohol.”
- D. “I will turn off my hearing aid when not in use.”
Correct answer: A
Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.
5. The healthcare provider is preparing a client with deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO prior to the test
- B. Client should receive a sedative medication before the test
- C. Discontinue anticoagulant therapy before the test
- D. No special preparation is necessary
Correct answer: D
Rationale: No special preparation is required for a Venous Doppler evaluation. Option A is incorrect because there is no need for the client to be NPO (nothing by mouth) before this test. Option B is incorrect as sedative medication is not typically administered for a Venous Doppler evaluation. Option C is incorrect as discontinuing anticoagulant therapy before the test may not be safe for a client with DVT, as it could increase the risk of developing a blood clot. Therefore, the correct answer is D.
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