HESI LPN
HESI Fundamentals 2023 Test Bank
1. When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first?
- A. Establish a new nursing diagnosis.
- B. Note which actions were not implemented.
- C. Add additional nursing orders to the plan.
- D. Collaborate with the healthcare provider to make changes.
Correct answer: B
Rationale: The correct first action for the LPN to take when a desired outcome is not achieved is to note which actions were not implemented. This step helps in identifying gaps in the plan of care and reasons for not achieving the desired outcome. Establishing a new nursing diagnosis (Choice A) is not the initial step when evaluating the plan of care. Adding additional nursing orders (Choice C) may not address the root cause of the unachieved outcome. Collaborating with the healthcare provider (Choice D) should come after identifying the gaps in the plan and reasons for the outcome not being met.
2. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?
- A. ''I think I should take my pain medication more often since it is not controlling my pain.''
- B. ''Breathing faster will help me keep my mind off of the pain.''
- C. ''It might help me to listen to music while I'm lying in bed.''
- D. ''I don't want to walk today because I have some pain.''
Correct answer: C
Rationale: The correct answer is C because listening to music is an effective nonpharmacological intervention for managing mild pain. Choice A is incorrect as increasing the frequency of pain medication without consulting healthcare providers can lead to adverse effects. Choice B is incorrect as distracting techniques like breathing faster may not address the pain effectively. Choice D is incorrect as avoidance of physical activity due to pain can hinder postoperative recovery.
3. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
- A. "What is your reason for wanting such a plan?"
- B. "Have you talked with your health care provider about this?"
- C. "Let us discuss your rights as a couple."
- D. "Write your ideal plan for the next class."
Correct answer: C
Rationale: Discussing the rights as a couple allows for open communication and helps ensure that the birthing plan aligns with the couple's preferences and medical advice.
4. Food energy is commonly expressed in kilocalories and in what other unit?
- A. kilojoules
- B. kilograms
- C. kilometers
- D. kilonewtons
Correct answer: A
Rationale: Food energy is commonly expressed in kilocalories and kilojoules. Kilocalories and kilojoules are both units of energy commonly used to measure the energy content of food. Kilograms, kilometers, and kilonewtons are units of mass, distance, and force, respectively, and are not used to express food energy.
5. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Intellectualization
Correct answer: A
Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.