HESI LPN
HESI Fundamentals Practice Questions
1. Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?
- A. Height in inches or centimeters.
- B. Weight in kilograms or pounds.
- C. Triceps skinfold thickness.
- D. Upper arm circumference.
Correct answer: D
Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.
2. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?
- A. Massage the calf and foot
- B. Elevate the leg above the heart
- C. Check the pedal pulse in the affected leg
- D. Extend the leg and flex the foot
Correct answer: D
Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.
3. Which task could the PN safely delegate to the UAP?
- A. Oral feeding of a two-year-old child after application of a hip spica cast
- B. Assessment of the placement and patency of a NG tube
- C. Participation in staff rounds to record notes regarding client goals
- D. Evaluation of a client's incisional pain following narcotic administration
Correct answer: A
Rationale: The correct answer is A because oral feeding of a child is a task that can be safely delegated to an unlicensed assistive personnel (UAP). This task involves providing basic care and does not require specialized nursing skills. Choices B, C, and D involve assessments, recording client goals, and evaluating pain, respectively, which all require specialized nursing knowledge, judgment, and skills. These tasks are not within the scope of practice for a UAP.
4. A client with a productive cough and fever has been diagnosed with bacterial pneumonia and is being admitted to the unit from the emergency room. Which intervention should the practical nurse ensure has been done prior to the administration of antibiotics?
- A. Sputum specimen
- B. Set of vital signs
- C. Electrocardiogram
- D. Glucometer check
Correct answer: A
Rationale: Before initiating antibiotic therapy in a client with bacterial pneumonia, obtaining a sputum specimen for culture and sensitivity is essential. This helps identify the specific bacteria causing the infection and guides the selection of the most effective antibiotic treatment.
5. Unresolved feelings related to loss are most likely to be recognized during which phase of the therapeutic nurse-client relationship?
- A. Working
- B. Trusting
- C. Orientation
- D. Termination
Correct answer: D
Rationale: Unresolved feelings related to loss are often recognized and explored during the termination phase of the nurse-client relationship. This phase involves preparing the client for separation from the nurse, which can trigger unresolved feelings related to loss. During the termination phase, clients may confront their emotions about ending the therapeutic relationship and may also revisit unresolved issues or losses that have surfaced during the course of therapy. Choices A, B, and C are incorrect because the working phase focuses on active problem-solving and goal achievement, the trusting phase emphasizes establishing rapport and building trust, and the orientation phase involves initial introductions and orientation to the therapeutic process, respectively.