HESI LPN
HESI Fundamentals 2023 Test Bank
1. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?
- A. Check the drainage tubing for a kink
- B. Review the intake and output record
- C. Notify the healthcare provider
- D. Give the client 8 oz of water to drink
Correct answer: A
Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.
2. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
- A. Diffuse expiratory wheezing
- B. Loose, productive cough
- C. No relief from inhaler
- D. Fever and chills
Correct answer: A
Rationale: During an acute asthma attack, one of the expected assessments by the nurse would be diffuse expiratory wheezing. This occurs due to narrowed airways and increased airflow velocity. Choice B, a loose productive cough, is not typically associated with an asthma attack. Choice C, no relief from inhaler, may indicate ineffective treatment but is not a direct assessment finding related to the physical examination. Choice D, fever and chills, are not typical symptoms of an asthma attack and would not be expected findings during the initial assessment of an acute asthma attack.
3. 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.
4. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?
- A. Assess the client's mobility
- B. Evaluate the pedal pulses
- C. Monitor skin temperature
- D. Check for swelling
Correct answer: B
Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.
5. The nurse is preparing to administer a subcutaneous injection of enoxaparin (Lovenox). Which site is most appropriate for the LPN/LVN to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Abdomen
- D. Dorsogluteal site
Correct answer: C
Rationale: The abdomen is the most appropriate site for administering subcutaneous injections of enoxaparin (Lovenox). Enoxaparin is typically administered in the abdomen due to better absorption and reduced risk of injury to underlying structures. The deltoid muscle is not recommended for subcutaneous injections of enoxaparin due to the potential risk of injury to underlying structures. The ventrogluteal and dorsogluteal sites are more appropriate for intramuscular injections rather than subcutaneous injections.
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