HESI LPN
HESI Fundamentals Practice Questions
1. The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?
- A. Encourage the client to take deep breaths.
- B. Provide humidified oxygen via tracheostomy collar.
- C. Suction the tracheostomy tube as needed.
- D. Change the tracheostomy dressing daily.
Correct answer: C
Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.
2. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?
- A. Collect at least 2 inches of formed stool.
- B. Wear sterile gloves while obtaining the specimen.
- C. Use a culturette for specimen collection.
- D. Record the date and time the stool was collected.
Correct answer: A
Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.
3. Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?
- A. Height in inches or centimeters.
- B. Weight in kilograms or pounds.
- C. Triceps skinfold thickness.
- D. Upper arm circumference.
Correct answer: D
Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.
4. A client scheduled for arthroplasty expresses concern about the risk of acquiring an infection from a blood transfusion. Which of the following statements should the nurse make to the client?
- A. Donate autologous blood before the surgery
- B. Request a specific blood type from the donor
- C. Use blood from a family member
- D. Accept allogeneic blood without concerns
Correct answer: A
Rationale: The correct statement for the nurse to make to the client is to 'Donate autologous blood before the surgery.' Autologous blood donation involves collecting and storing the client's own blood for potential use during surgery, which significantly reduces the risk of transfusion-related infections. This option directly addresses the client's concern about infection risk. Requesting a specific blood type from a donor (Choice B) is not as effective in reducing infection risk compared to autologous blood donation. Using blood from a family member (Choice C) carries the risk of transfusion reactions and infections due to compatibility issues. Accepting allogeneic blood without concerns (Choice D) does not address the client's specific concern about infection risk and is not the most appropriate option in this situation.
5. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct answer: B
Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.
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