HESI LPN
HESI Fundamentals Exam
1. When a healthcare professional makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The healthcare professional's attempt to irrigate the tube with 10ml of 0.9% NaCl was unsuccessful, so they determine that the tube was obstructed. Which of the following actions should the healthcare professional take?
- A. Notify the healthcare provider.
- B. Attempt to irrigate the tube with a larger volume of saline.
- C. Replace the NG tube with a new one.
- D. Reposition the client to see if that helps the tube drain.
Correct answer: A
Rationale: If an NG tube is obstructed and cannot be irrigated successfully, notifying the healthcare provider is the appropriate action to take for further management. This is crucial as the healthcare provider may need to assess the situation, provide guidance, or intervene with specific interventions. Attempting to irrigate the tube with a larger volume of saline (Choice B) may exacerbate the situation if the tube is truly obstructed. Replacing the NG tube with a new one (Choice C) should not be the initial action unless advised by the healthcare provider. Repositioning the client (Choice D) may not necessarily resolve the tube obstruction and should not be the primary intervention in this scenario.
2. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?
- A. The presence and location of any pressure ulcers.
- B. Measures already taken to maintain client safety.
- C. Any special mattresses on the client’s bed.
- D. Current vital signs and oxygen saturation.
Correct answer: B
Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.
3. A client has sublingual nitroglycerine tablets prescribed to treat angina. The nurse realizes the client requires further education if the client makes which statements? (Select one that doesn't apply.)
- A. I will need to replace the nitroglycerine tablets every 3 to 5 months, not in a year.
- B. I should continue taking nitroglycerine tablets if I develop a headache.
- C. I understand nitroglycerine tablets do not cause addiction.
- D. If I feel dizzy when I take these, I should sit down or lie down until I feel better.
Correct answer: D
Rationale: The correct answer is D. Nitroglycerine sublingual tablets need to be replaced every 3 to 5 months, not every year, making statement A incorrect. While nitroglycerine can cause a headache, it is important to continue taking the prescribed nitroglycerine if the client has angina, making statement B accurate. Nitroglycerine tablets do not cause addiction, so statement C is correct. Dizziness and weakness are associated with the hypotensive effect of nitroglycerine; therefore, if the client feels dizzy when taking them, they should sit down or lie down until they feel better. Taking nitroglycerine tablets before an activity known to cause angina can help prevent angina attacks.
4. The following statements pertain to devolution as mandated by the local government code. Which of these is not correct?
- A. People can participate in policymaking relative to healthcare delivery.
- B. Devolution will enhance the quality of community life.
- C. The barangay shall set criteria as to who shall be given priority in the delivery of healthcare services.
- D. The DOH shall transfer regulatory function of inspecting food establishments to local government units.
Correct answer: D
Rationale: The correct answer is D. The Department of Health (DOH) retains regulatory functions for inspecting food establishments, and it is not transferred to local government units. Choices A, B, and C are correct because devolution allows people to participate in policymaking for healthcare, enhances community life quality, and empowers the barangay to set criteria for healthcare service prioritization.
5. The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?
- A. Providing nail care
- B. Teaching foot care
- C. Making the patient's bed
- D. Determining aspiration risk
Correct answer: C
Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.