HESI LPN
Fundamentals of Nursing HESI
1. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned infants.
- B. Port wine stains are typically associated with other malformations.
- C. Telangiectatic nevi are normal and will disappear as the baby grows.
- D. The child is too young for surgical removal of these at this time.
Correct answer: C
Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.
2. In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to
- A. Stabilize alveolar surface tension
- B. Maintain alveolar surface tension
- C. Promote normal pulmonary blood flow
- D. Regulate intra-cardiac pressure
Correct answer: B
Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.
3. Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.
4. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Carry a client's soiled linens out of the room in a mesh linen bag
- B. Place a client who has tuberculosis in a room with negative-pressure airflow
- C. Provide disposable plates and utensils for a client who is HIV-positive
- D. Dispose of a client's blood-saturated dressing in a biohazard bag
Correct answer: B
Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.
5. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?
- A. Pain related to ischemia
- B. Risk for altered elimination: constipation
- C. Risk for complication: dysrhythmias
- D. Anxiety related to pain
Correct answer: A
Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.
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