HESI LPN
Fundamentals of Nursing HESI
1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most appropriate?
- A. Ask the wife how she would like to participate in the client's care
- B. Provide the wife with information about hospice
- C. Encourage the wife to visit during the treatment process
- D. Refer her to a support group for family members of those with terminal cancer
Correct answer: A
Rationale: In this situation, it is crucial to involve the wife in the care of the client to provide support and empower her. Asking the wife how she would like to participate allows her to be actively involved in decision-making and caregiving. Providing information about hospice (choice B) might be premature as the couple may still be digesting the diagnosis. Encouraging the wife to visit during the treatment process (choice C) may not address her immediate need for involvement and support. Referring her to a support group for family members (choice D) is helpful but involving her directly in the client's care is a more immediate and personalized approach.
2. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?
- A. Confirm unresponsiveness
- B. Check for a pulse
- C. Begin chest compressions
- D. Call for emergency help
Correct answer: A
Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.
3. A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hypertension
- D. Hyperkalemia
Correct answer: B
Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.
4. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?
- A. Shortness of breath on exertion
- B. Weight gain of 2 pounds in a week
- C. Orthopnea
- D. Crackles in the lungs
Correct answer: D
Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.
5. A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?
- A. Daily weight
- B. Intake and output
- C. Urine specific gravity
- D. Peripheral edema
Correct answer: A
Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.
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