HESI LPN
Community Health HESI Practice Exam
1. You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
- A. ''I will be receiving continuous doses of medication.''
- B. ''I should call the nurse before I take additional doses.''
- C. ''I will call for assistance if my pain is not relieved.''
- D. ''The machine will prevent an overdose.''
Correct answer: B
Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.
2. A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
- A. “I will place the client on their side.”
- B. “I will go to the nurses’ station for assistance.”
- C. “I will note the time that the seizure begins.”
- D. “I will prepare to insert an airway.”
Correct answer: B
Rationale: The correct answer is B. Going to the nurses’ station for assistance during a seizure is inappropriate as immediate care is necessary. Placing the client on their side helps maintain an open airway and prevents aspiration. Noting the time the seizure begins is crucial for monitoring and documentation. Preparing to insert an airway may be necessary if the client's airway becomes compromised. Therefore, the nurse's statement about going to the nurses' station for assistance is the only incorrect response as it delays essential care.
3. A 2-week-old infant is admitted with a tentative diagnosis of a ventricular septal defect. The parents report that their baby has had difficulty feeding since coming home after birth. What should the nurse consider before responding?
- A. Feeding problems are common in neonates.
- B. Inadequate sucking is not significant in the absence of cyanosis.
- C. Ineffective sucking and swallowing may be early indications of a heart defect.
- D. Many neonates retain mucus, which may interfere with feeding for several weeks.
Correct answer: C
Rationale: In this scenario, the nurse should consider that ineffective sucking and swallowing in a 2-week-old infant could be early signs of a heart defect such as a ventricular septal defect. This is crucial information as it can guide further assessment and management. Choice A is incorrect because while feeding problems can be common in neonates, in this case, the specific context of a suspected heart defect should be prioritized. Choice B is incorrect as inadequate sucking can indeed be significant, especially when considering potential underlying heart issues, regardless of the presence of cyanosis. Choice D is incorrect as while mucus retention can affect feeding, in this case, the focus should be on the possibility of a heart defect rather than a temporary issue like mucus interference.
4. What is the recommended first step in the management of a child with a suspected head injury?
- A. Administer pain medication
- B. Assess the child's level of consciousness
- C. Perform a CT scan
- D. Monitor for seizures
Correct answer: B
Rationale: The correct first step in managing a child with a suspected head injury is to assess the child's level of consciousness. This assessment is crucial as it helps determine the severity of the injury and guides further management. Administering pain medication (Choice A) should not be done before assessing the level of consciousness. Performing a CT scan (Choice C) may be necessary but is not the initial step. Monitoring for seizures (Choice D) is important but comes after assessing the child's level of consciousness.
5. What is the significance of patient advocacy in nursing?
- A. Prioritizing the needs of the healthcare team over the patient
- B. Ensuring that patients' rights and preferences are respected
- C. Limiting patient autonomy
- D. Focusing solely on clinical procedures
Correct answer: B
Rationale: Patient advocacy in nursing entails ensuring that patients' rights and preferences are respected. This involves advocating for the patients' best interests, supporting informed decision-making, and safeguarding their autonomy. Choice A is incorrect because patient advocacy focuses on the patient's needs, not the healthcare team's. Choice C is incorrect as patient advocacy aims to empower patients and enhance their autonomy rather than limiting it. Choice D is incorrect since patient advocacy goes beyond clinical procedures to encompass holistic care that addresses the patients' preferences and rights.