HESI LPN
HESI Fundamentals Exam Test Bank
1. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. Allergies
- B. Scabies
- C. Regression
- D. Pinworms
Correct answer: D
Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.
2. A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?
- A. Elevate the head of the bed.
- B. Remove the inner cannula.
- C. Irrigate the stoma.
- D. Discontinue suctioning.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.
3. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Request a consultation with the ethics committee
- D. Ask the client's family to intervene
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.
4. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
- A. HR 105/min
- B. BMI 25 kg/m²
- C. BP 148/92
- D. Glucose 45 mg/dL
Correct answer: D
Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.
5. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct answer: A
Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI LPN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access