HESI LPN
Fundamentals of Nursing HESI
1. 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.
2. A healthcare professional is reviewing a client’s medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the healthcare professional should identify that this combination is likely to result in which of the following effects?
- A. Decreased therapeutic effects of cimetidine
- B. Increased risk of imipramine toxicity
- C. Decreased risk of adverse effects of cimetidine
- D. Increased therapeutic effects of imipramine
Correct answer: B
Rationale: When cimetidine decreases the metabolism of imipramine, it leads to an increased concentration of imipramine in the body, which can result in imipramine toxicity. This increased risk of toxicity is the likely effect of this drug interaction. Choice A is incorrect because cimetidine's effect on imipramine metabolism does not impact the therapeutic effects of cimetidine. Choice C is incorrect because the interaction does not decrease the risk of adverse effects of cimetidine. Choice D is incorrect as the increased concentration of imipramine can lead to toxicity, not increased therapeutic effects.
3. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?
- A. Call the Poison Control Center as soon as the situation is identified
- B. Empty the child's mouth in any case of possible poisoning
- C. Have the child move minimally if a toxic substance was inhaled
- D. Do not induce vomiting if the poison is a hydrocarbon
Correct answer: B
Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.
4. A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?
- A. Choose the most distal site on the selected extremity
- B. Apply a cool compress to the selected extremity before insertion of the IV catheter
- C. Stroke the selected extremity before insertion of the IV catheter
- D. Place the tourniquet above the proposed insertion site
Correct answer: C
Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.
5. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?
- A. Calf swelling
- B. Elevated blood pressure
- C. Decreased urine output
- D. Generalized rash
Correct answer: A
Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.
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