HESI LPN
HESI Fundamentals Practice Questions
1. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?
- A. Ensure the client wears a mask when outside the room if there is construction nearby.
- B. Place the client in a private room with positive pressure airflow.
- C. Restrict all visitors from seeing the client.
- D. Provide a HEPA filter in the client's room.
Correct answer: A
Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.
2. 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.
3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102°F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse’s priority?
- A. Temperature
- B. Menses overdue
- C. Soft tender abdomen
- D. Heart rate
Correct answer: A
Rationale: The correct answer is A: Temperature. A high temperature of 39.2°C (102°F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.
4. When planning to insert a peripheral IV catheter for an older adult client, which of the following actions should the nurse plan to take?
- A. Insert the catheter at a 45° angle
- B. Place the client's arm in a dependent position
- C. Shave excess hair from the insertion site
- D. Initiate IV therapy in the veins of the hand
Correct answer: B
Rationale: Placing the client's arm in a dependent position is the correct action when inserting a peripheral IV catheter for an older adult client. This position helps veins dilate due to gravity, facilitating easier insertion of the IV catheter. Choice A is incorrect because catheters are typically inserted at a lower angle, around 10-30 degrees. Choice C is unnecessary unless excessive hair impedes the insertion process. Choice D is incorrect as veins in the hand are generally smaller and more prone to complications, making them less ideal for IV therapy in older adults.
5. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct answer: D
Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.
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