HESI LPN
HESI Fundamentals Exam Test Bank
1. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?
- A. Absent bowel sounds
- B. Pain level of 8/10
- C. Temperature of 100.4°F
- D. Saturated abdominal dressing
Correct answer: D
Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.
2. A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts?
- A. Defamation - harming someone's reputation through false statements.
- B. Malpractice - professional negligence or misconduct.
- C. Assault - threatening to cause harm to someone.
- D. Battery - intentional harmful or offensive physical contact.
Correct answer: C
Rationale: In this scenario, the colleague's action of informing the client that he will administer medication by injection if she refuses to swallow her pills constitutes assault. Assault is the act of threatening harm that causes fear of imminent harm. It does not involve physical contact but rather the apprehension of an imminent harmful or offensive act. Defamation, choice A, is incorrect as it involves harming someone's reputation through false statements. Malpractice, choice B, is also incorrect as it refers to professional negligence or misconduct in performing duties. Battery, choice D, is not the correct answer as it involves intentional harmful or offensive physical contact with the person.
3. A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:
- A. Solutes in the urine
- B. Bacteria in the urine
- C. pH level of the urine
- D. Glucose in the urine
Correct answer: A
Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.
4. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?
- A. Adolescent
- B. Preschooler
- C. Older adult
- D. Adult
Correct answer: B
Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.
5. A client has been diagnosed with terminal cancer. Which of the following interventions is a priority?
- A. Teach the client to use progressive relaxation techniques.
- B. Help the client find a local support group.
- C. Discuss the client's prior coping mechanisms.
- D. Develop a list of goals with the client.
Correct answer: D
Rationale: When a client receives a terminal cancer diagnosis, it is crucial to prioritize developing a list of goals with the client. This process helps the client focus on what is important to them, set achievable objectives, and maintain a sense of purpose and control. Teaching relaxation techniques (choice A) may be beneficial for symptom management but is not the priority when confronting a terminal illness. While finding a local support group (choice B) can be valuable for emotional support, it does not directly address setting goals. Discussing prior coping mechanisms (choice C) can provide insights into the client's coping strategies but may not be as essential as establishing future goals in the face of a terminal illness.
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