HESI LPN
HESI Fundamental Practice Exam
1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?
- A. Place the client in a side-lying position
- B. Instill 15 mL of irrigation fluid into the catheter with each flush
- C. Subtract the amount of irrigant used from the client's urine output
- D. Perform the irrigation using a 20 mL syringe
Correct answer: C
Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.
2. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the nurse to take?
- A. Administer oxygen via a nasal cannula.
- B. Measure the client's vital signs.
- C. Obtain a 12-lead ECG.
- D. Encourage the client to use pursed-lip breathing.
Correct answer: A
Rationale: Administering oxygen via a nasal cannula is the priority action for a client experiencing chest pain due to coronary artery disease. Oxygen therapy helps improve oxygenation, reduce myocardial workload, and relieve chest pain by increasing oxygen delivery to the heart muscle. While measuring vital signs, obtaining a 12-lead ECG, and encouraging pursed-lip breathing are important interventions, administering oxygen takes precedence in this situation to address the potential hypoxemia associated with chest pain in a client with a history of coronary artery disease.
3. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:
- A. Be at an increased susceptibility for infection
- B. Have a wound that heals more slowly
- C. Experience more pain during the healing process
- D. Require more frequent dressing changes
Correct answer: A
Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.
4. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
- A. Slower light touch sensation
- B. Some vision and hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
Correct answer: B
Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.
5. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself every day at the same time.
- B. I will call my doctor if my legs swell more.
- C. I will take my water pill only when I feel short of breath.
- D. I will limit the amount of salt in my diet.
Correct answer: C
Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.
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