HESI LPN
HESI Practice Test for Fundamentals
1. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?
- A. Risk for aspiration
- B. Impaired physical mobility
- C. Disturbed sensory perception
- D. Interrupted family processes
Correct answer: A
Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.
2. A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?
- A. Administer a bronchodilator as prescribed
- B. Encourage the client to drink fluids
- C. Place the client in an upright position
- D. Assess the client's peak flow rate
Correct answer: A
Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.
3. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?
- A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
- B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
- C. The arms should be crossed over the chest or in the lap.
- D. The feet should be close together with toes pointed out.
Correct answer: A
Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.
4. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?
- A. Apply a pulse oximeter
- B. Measure blood pressure
- C. Notify the charge nurse
- D. Observe pressure areas
Correct answer: C
Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.
5. A client with asthma is receiving long-term glucocorticoid therapy. The nurse includes a risk for impaired skin integrity on the client's problem list. What is the rationale for including this problem?
- A. Abnormal fat deposits impair circulation
- B. Frequent diarrhea can lead to skin issues
- C. Thinned skin bruises easily
- D. Decreased serum glucose prolongs healing time
Correct answer: C
Rationale: The correct answer is C. Glucocorticoids can cause skin thinning, which increases the likelihood of bruising. Thinning of the skin due to glucocorticoid therapy makes it more fragile and prone to injury, such as bruising, even with minimal trauma. Choices A, B, and D are incorrect because abnormal fat deposits impairing circulation, frequent diarrhea causing skin issues, and decreased serum glucose prolonging healing time are not direct effects of glucocorticoid therapy on skin integrity.