HESI LPN
HESI Fundamental Practice Exam
1. Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16-year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20-year-old in skeletal traction for 2 weeks since a motorcycle accident
- C. 72-year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75-year-old who is in skin traction prior to planned hip pinning surgery
Correct answer: C
Rationale: The 72-year-old recovering from surgery after a hip replacement 2 hours ago should be seen first due to the potential for immediate post-operative complications. This patient is in the immediate postoperative period and requires close monitoring for any signs of complications such as bleeding, infection, or impaired circulation. The other patients are relatively stable compared to the patient who just had surgery and therefore can wait for assessment and care without immediate risk. The 16-year-old had surgery ten hours ago, which is longer than the 72-year-old and is at a lower risk for immediate complications. The 20-year-old in skeletal traction for two weeks is stable in his current condition. The 75-year-old in skin traction before planned surgery does not require immediate attention as the surgery has not yet taken place.
2. The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?
- A. Check the placement of the tube by auscultation.
- B. Flush the tube with 30 ml of water before and after medication administration.
- C. Administer the medication with food to prevent nausea.
- D. Dilute the medication with normal saline before administration.
Correct answer: B
Rationale: To ensure proper administration through a nasogastric tube, the LPN/LVN should flush the tube with 30 ml of water before and after medication administration. This action helps ensure the tube is patent, prevents clogging, and helps deliver the medication effectively. Checking the placement of the tube by auscultation (Choice A) is essential but does not directly relate to ensuring proper administration. Administering the medication with food (Choice C) may not always be appropriate for all medications and may not necessarily prevent nausea. Diluting the medication with normal saline (Choice D) is not a standard practice for all medications administered via an NG tube and may alter the medication's effectiveness.
3. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?
- A. Assess surfaces exposed to the edges of the cast for pressure areas.
- B. Keep the patient's blood pressure low to prevent overperfusion of tissue.
- C. Allow turning in bed to prevent complications.
- D. Encourage the patient's dietary intake to maintain hydration.
Correct answer: A
Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.
4. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?
- A. Ensure sterilization of non-disposable items with ethylene oxide
- B. Wrap monitoring cords with stockinette and secure them with non-latex tape
- C. Cleanse latex ports on IV tubing with chlorhexidine before administering medication
- D. Wear hypoallergenic latex gloves that are powder-free
Correct answer: B
Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.
5. A client with chronic kidney disease is being assessed. Which laboratory value would be most concerning?
- A. Serum creatinine of 3.0 mg/dL
- B. Blood urea nitrogen (BUN) of 45 mg/dL
- C. Serum potassium of 6.5 mEq/L
- D. Hemoglobin of 10 g/dL
Correct answer: C
Rationale: In a client with chronic kidney disease, an elevated serum potassium level (hyperkalemia) is the most concerning finding. Hyperkalemia can lead to life-threatening cardiac dysrhythmias due to its effect on the electrical conduction system of the heart. Monitoring and managing serum potassium levels are crucial in patients with chronic kidney disease to prevent serious complications. While elevated serum creatinine (Choice A) and Blood Urea Nitrogen (BUN) levels (Choice B) indicate impaired kidney function, hyperkalemia poses an immediate risk of cardiac complications. Hemoglobin levels (Choice D) are typically lower in chronic kidney disease due to decreased erythropoietin production, but they do not present an immediate life-threatening risk like hyperkalemia.
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