HESI LPN
HESI Fundamentals Practice Questions
1. A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?
- A. Increased urine output
- B. Decreased blood pressure
- C. Increased heart rate
- D. Increased respiratory rate
Correct answer: B
Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.
2. A client has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
- A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
- B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
- C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
- D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.
Correct answer: A
Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.
3. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
- A. Erythema along the path of the vein
- B. Pitting edema at the insertion site
- C. Coolness of the client’s left forearm
- D. Pallor of the client’s left forearm
Correct answer: A
Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.
4. A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
- A. A 10-month-old infant can pull up to a standing position.
- B. A 6-month-old infant can walk with assistance.
- C. A 12-month-old infant can jump with both feet.
- D. An 8-month-old infant can crawl on hands and knees.
Correct answer: A
Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.
5. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.
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