HESI LPN
Fundamentals of Nursing HESI
1. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?
- A. Obtain the pre-transfusion hemoglobin level.
- B. Prime the tubing and set up the blood pump.
- C. Monitor vital signs every 15 minutes for the first hour.
- D. Ensure the accuracy of the blood type match.
Correct answer: D
Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.
2. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?
- A. Elevate the head of the bed to 30-45 degrees.
- B. Check residual volumes every 4 hours.
- C. Verify tube placement every shift.
- D. Flush the tube with water every 4 hours.
Correct answer: A
Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.
3. A client is being discharged with a prescription for digoxin (Lanoxin). Which of the following instructions should the nurse include in the discharge teaching?
- A. Take your pulse daily before taking this medication.
- B. Take an extra dose if you miss a dose of this medication.
- C. Take this medication with food.
- D. Avoid eating foods high in potassium while taking this medication.
Correct answer: A
Rationale: The correct answer is A: 'Take your pulse daily before taking this medication.' It is essential for clients taking digoxin to monitor their pulse daily to detect bradycardia, a potential side effect. Choice B is incorrect because clients should never take an extra dose if a dose is missed; they should take the missed dose as soon as remembered unless it is close to the time for the next dose. Choice C is incorrect because digoxin is preferably taken with food to minimize gastrointestinal side effects. Choice D is incorrect because digoxin itself can cause low potassium levels, so avoiding potassium-rich foods is not necessary.
4. A healthcare provider is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the healthcare provider take?
- A. Insert the IV catheter without using a tourniquet.
- B. Use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
- C. Insert the IV catheter at a 45-degree angle.
- D. Use a smaller gauge catheter to reduce vein trauma.
Correct answer: B
Rationale: When initiating IV therapy in older adults, it is essential to use the tourniquet minimally or not at all to prevent potential injury to fragile skin or veins. The use of a tourniquet can lead to increased venous pressure and potentially cause vein damage in older adult clients. Choice A is incorrect because inserting the IV catheter without a tourniquet can make locating veins more challenging. Choice C is incorrect as inserting the IV catheter at a 45-degree angle is not a recommended practice and can increase the risk of complications. Choice D is incorrect because using a smaller gauge catheter may not be appropriate for older adults who may require a larger gauge catheter for adequate fluid administration.
5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
- A. Infuse normal saline at a keep-vein-open rate.
- B. Discontinue the IV and flush the port with heparin.
- C. Infuse 10% dextrose and water at 54 ml/hr.
- D. Obtain a stat blood glucose level and notify the healthcare provider.
Correct answer: C
Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.
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