HESI LPN
HESI Fundamentals 2023 Test Bank
1. An 80-year-old client admitted with a diagnosis of a possible cerebral vascular accident has had a blood pressure ranging from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the healthcare provider?
- A. Slurred speech
- B. Incontinence
- C. Muscle weakness
- D. Rapid pulse
Correct answer: A
Rationale: Slurred speech is a classic sign of a worsening stroke, suggesting a potential blockage or hemorrhage affecting speech centers in the brain. Prompt reporting of this symptom to the healthcare provider is crucial for immediate evaluation and intervention. While incontinence (Choice B) is important to monitor, it is not considered an immediate priority over slurred speech in this context. Muscle weakness (Choice C) and rapid pulse (Choice D) are also relevant in stroke assessment, but slurred speech takes precedence due to its strong association with neurological deficits in the setting of a possible cerebral vascular accident.
2. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?
- A. Examine the elbow
- B. Administer pain medication
- C. Apply a warm compress to the elbow
- D. Assess the client’s range of motion
Correct answer: A
Rationale: The appropriate initial action for the nurse is to examine the elbow. This step is crucial to assess the site of pain, identify any visible signs of injury or inflammation, and determine the cause of the discomfort. Administering pain medication (Choice B) should come after a thorough assessment. Applying a warm compress (Choice C) might provide temporary relief but does not address the underlying cause. Assessing the client’s range of motion (Choice D) is important but would come after the initial examination to further evaluate the elbow joint.
3. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?
- A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
- B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
- C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
- D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”
Correct answer: B
Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.
4. A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?
- A. Raise the level of the bed
- B. Administer mouth care with the client in a supine position
- C. Use a tongue depressor to open the mouth
- D. Place the client in a prone position
Correct answer: A
Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.
5. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Occupational therapist
- D. Speech-language pathologist
Correct answer: D
Rationale: The correct answer is D, Speech-language pathologist. Speech-language pathologists specialize in assessing and treating dysphagia, which is a common issue following a cerebrovascular accident. They are trained to evaluate swallowing function and provide appropriate interventions to help clients improve their ability to swallow safely. Choice A, Social worker, is incorrect as their role does not typically involve addressing dysphagia specifically. Choice B, Certified nursing assistant, is not the appropriate professional to address dysphagia concerns as they do not have the training or scope of practice for this specialized area. Choice C, Occupational therapist, focuses more on activities of daily living and functional abilities rather than the specialized treatment of dysphagia.
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