HESI LPN
HESI Fundamentals 2023 Test Bank
1. Which serum blood finding in diabetic ketoacidosis alerts the nurse that immediate action is required?
- A. pH below 7.3
- B. Potassium of 5.0
- C. HCT of 60
- D. PaO2 of 79%
Correct answer: C
Rationale: A hematocrit (HCT) of 60 indicates severe dehydration, a critical condition in diabetic ketoacidosis that requires immediate intervention. Severe dehydration can lead to hypovolemic shock and organ failure. While a low pH below 7.3 is indicative of acidosis, it may not require immediate action compared to severe dehydration. A potassium level of 5.0 is within the normal range and not a critical finding in this scenario. PaO2 of 79% reflects oxygenation status, which is important but not the most critical finding requiring immediate action in diabetic ketoacidosis.
2. A client has experienced a fetal demise following a vaginal delivery at term. What should the nurse advise the client?
- A. “You can bathe and dress your baby if you’d like to.”
- B. “If you don’t hold the baby, it will make letting go much harder.”
- C. “You should name the baby so he/she can have an identity.”
- D. “I’m sure you will be able to have another baby when you’re ready.”
Correct answer: A
Rationale: After a fetal demise, allowing the parents to bathe and dress their baby can offer them a sense of closure and help them in their grieving process. This act can provide a tangible way for the parents to bond with their baby and create lasting memories. Option B is incorrect because each individual may have different emotional needs and holding the baby may not be appropriate or helpful for everyone. Option C, while well-intentioned, may not be suitable for all parents as naming the baby could be emotionally challenging. Option D is insensitive as it overlooks the grieving process of losing a baby by suggesting a replacement.
3. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
- A. Raising the side rails and placing the call bell within reach
- B. Teaching the client how to push to decrease the length of the second stage of labor
- C. Timing and recording uterine contractions
- D. Positioning the client for proper distribution of anesthesia
Correct answer: D
Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to position the client for proper distribution of anesthesia. Proper positioning ensures effective pain management during labor, optimizing the effects of the regional anesthesia. While raising the side rails and placing the call bell within reach (choice A) is important for safety, teaching the client how to push (choice B) and timing and recording uterine contractions (choice C) are vital aspects of care but are not the highest priority immediately after administering regional anesthesia.
4. A client with diabetes mellitus type 1 is prescribed insulin lispro. When should the nurse instruct the client to administer this medication?
- A. 5-10 minutes before meals
- B. 15 minutes after meals
- C. 30 minutes before meals
- D. 1 hour after meals
Correct answer: A
Rationale: Corrected Rationale: Insulin lispro is a rapid-acting insulin that should be administered 5-10 minutes before meals. This timing helps synchronize the peak action of insulin with the rise in blood glucose levels after eating, effectively managing postprandial hyperglycemia. Choice B, administering 15 minutes after meals, is incorrect because rapid-acting insulins like lispro are meant to act quickly to cover the rise in blood glucose levels after meals. Choices C and D are also incorrect as they do not align with the rapid onset of action required to manage postprandial hyperglycemia in patients with diabetes mellitus type 1.
5. A parent tearfully tells a nurse, 'They think our child is developmentally delayed. We are thinking about investigating a preschool program for cognitively impaired children.' What is the nurse’s most appropriate response?
- A. Praise the parent for the decision and encourage the plan.
- B. Ask for more specific information related to the developmental delays.
- C. Advise the parent to have the healthcare provider help choose an appropriate program.
- D. Explain that this may be a premature action and the developmental delays could disappear.
Correct answer: B
Rationale: The most appropriate response for the nurse in this situation is to ask for more specific information related to the developmental delays. By seeking additional details, the nurse can better understand the situation, offer appropriate support, and provide guidance tailored to the child's specific needs. Praising the parent or encouraging the plan without understanding the full context may not be beneficial. Advising the parent to have the healthcare provider help choose a program assumes the parent has not already involved the healthcare provider, which may not be the case. Explaining that the developmental delays could disappear is not appropriate as it may give false hope or minimize the parent's concerns.