HESI LPN
HESI Fundamentals Test Bank
1. UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?
- A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
- B. The urine meter attached to the urinary drainage bag is completely full.
- C. There is a large dependent loop in the client's urinary drainage tubing.
- D. Purulent drainage is present around the insertion site of the feeding tube.
Correct answer: D
Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.
2. During passive range of motion (ROM) and splinting, the absence of which finding will indicate goal achievement for these interventions?
- A. Atelectasis
- B. Renal calculi
- C. Pressure ulcers
- D. Joint contractures
Correct answer: D
Rationale: The correct answer is D: Joint contractures. When a healthcare provider performs passive ROM and splinting on a patient, the goal is to prevent joint contractures. Joint contractures result from immobility and can lead to permanent stiffness and decreased range of motion. Atelectasis (choice A) is a condition where there is a complete or partial collapse of the lung, commonly due to immobility, but not directly related to passive ROM or splinting. Renal calculi (choice B) are kidney stones and are not typically associated with ROM exercises. Pressure ulcers (choice C) result from prolonged pressure on the skin and are prevented by repositioning the patient, not specifically addressed by ROM and splinting exercises.
3. How is the diagnosis of Hirschsprung disease confirmed in a 1-month-old infant admitted to the pediatric unit?
- A. Colonoscopy
- B. Rectal biopsy
- C. Multiple saline enemas
- D. Fiberoptic nasoenteric tube
Correct answer: B
Rationale: Rectal biopsy is the definitive diagnostic procedure for Hirschsprung disease in infants. It confirms the absence of ganglion cells in the affected bowel segment, which is characteristic of Hirschsprung disease. Colonoscopy (Choice A) is not typically used for confirmation as it may not provide a definitive result. Multiple saline enemas (Choice C) are utilized in the treatment of meconium ileus, a complication of cystic fibrosis, and not in the diagnosis of Hirschsprung disease. Fiberoptic nasoenteric tube (Choice D) is not a diagnostic tool for Hirschsprung disease; it is commonly used for gastrointestinal decompression or feeding purposes but does not confirm the diagnosis.
4. Which of the following statements is a characteristic of supermales?
- A. They are somewhat taller than average.
- B. Their facial hair growth is minimal when compared to normal males.
- C. They suffer from gynecomastia.
- D. They are typically impotent.
Correct answer: A
Rationale: The correct characteristic of supermales, individuals with an XYY chromosome pattern, is that they are somewhat taller than average. Choice B is incorrect as supermales do not exhibit minimal facial hair growth compared to normal males. Choice C is incorrect as gynecomastia, the development of male breasts, is not a characteristic of supermales. Choice D is also incorrect as impotence is not a typical characteristic associated with supermales.
5. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage?
- A. Place a 4x4 wick in the stoma opening
- B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
- C. Cut the bag opening to the measurement of the stoma size
- D. Administer a PRN antidiarrheal agent
Correct answer: C
Rationale: To prevent leakage of stool under the disposable ostomy bag, the nurse should cut the bag opening to the measurement of the stoma size. This action ensures a proper fit, which is crucial in preventing leaks that can lead to skin irritation and compromise stoma care. Placing a 4x4 wick in the stoma opening or applying zinc oxide ointment may not address the issue of leakage effectively. Administering a PRN antidiarrheal agent is not directly related to preventing leakage caused by an ill-fitting ostomy bag.