HESI LPN
Community Health HESI Test Bank
1. When assessing a newborn infant with low set ears, short palpebral fissures, flat nasal bridge, and an indistinct philtrum, a priority maternal assessment by the nurse should be to ask about
- A. Alcohol use during pregnancy
- B. Usual nutritional intake
- C. Family genetic disorders
- D. Maternal and paternal ages
Correct answer: A
Rationale: The correct answer is A: Alcohol use during pregnancy. The physical features mentioned are indicative of fetal alcohol syndrome, a condition caused by maternal alcohol consumption during pregnancy. It is crucial for the nurse to inquire about alcohol use as it can help in diagnosing and managing the infant's condition. Choices B, C, and D are incorrect as they are not directly associated with the physical findings described in the newborn, which specifically point towards a potential history of alcohol exposure during pregnancy.
2. To individualize care for a client and ensure maximum participation in that care, what should the nurse consider as the most important factor in planning the said care?
- A. environment
- B. educational attainment
- C. health beliefs and practices
- D. health status
Correct answer: C
Rationale: The correct answer is C: health beliefs and practices. Health beliefs and practices directly influence a client's willingness and ability to participate in care. Understanding a client's health beliefs and practices helps the nurse tailor the care plan to align with the client's values and preferences. Choice A, environment, though important, may not be the most critical factor in individualizing care. Choice B, educational attainment, is relevant but not as significant as understanding the client's health beliefs and practices. Choice D, health status, is essential but does not address the individualization of care and maximizing participation as directly as health beliefs and practices.
3. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?
- A. Administration of cough suppressants
- B. Increasing oral fluid intake to 3000 cc per day
- C. Maintaining bed rest with bathroom privileges
- D. Performing chest physiotherapy twice a day
Correct answer: B
Rationale: Increasing oral fluid intake to 3000 cc per day is the most effective in removing respiratory secretions in a client with pneumococcal pneumonia. Adequate hydration helps thin secretions, making them easier to expectorate. Administration of cough suppressants (Choice A) may hinder the removal of secretions by suppressing the cough reflex. Maintaining bed rest with bathroom privileges (Choice C) is important but does not directly address the removal of respiratory secretions. Performing chest physiotherapy (Choice D) is beneficial for mobilizing secretions but may not be as effective as increasing fluid intake in thinning and facilitating the removal of secretions.
4. The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
- A. Infant will experience minimal pain
- B. Muscle spasms will be relieved
- C. Mobility will be managed as tolerated
- D. Tissue perfusion will be maintained
Correct answer: D
Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.
5. At a nursing staff meeting, there is a discussion of perceived inequities in weekend staff assignments. As a follow-up, what should the nurse manager do initially?
- A. Allow the staff to change assignments
- B. Clarify reasons for current assignments
- C. Help staff see the complexity of issues
- D. Facilitate creative thinking on staffing
Correct answer: D
Rationale: Facilitating creative thinking on staffing is the most appropriate initial action for the nurse manager in addressing perceived inequities in weekend staff assignments. By encouraging creative thinking, the manager promotes innovative solutions and fosters a sense of ownership and collaboration among staff members. Choices A, B, and C are not the best initial steps in this situation. Allowing staff to change assignments may not address the underlying issues, clarifying reasons for current assignments may not resolve perceived inequities, and helping staff see the complexity of issues may not lead to actionable solutions.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99