a client with a diagnosis of hypertension is being assessewhich symptom would be most concerning
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

2. When teaching a client and their family how to care for the client’s tracheostomy at home, which of the following should the nurse include?

Correct answer: A

Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.

3. The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?

Correct answer: B

Rationale: The correct answer is B. Flossing is essential for removing plaque and tartar between teeth, contributing to better oral hygiene. Choice A is not entirely accurate as waxed floss may not solely prevent bleeding. Flossing three times a day, as mentioned in choice C, can be excessive and unnecessary, while choice D is incorrect as applying toothpaste before flossing is not harmful but might not provide additional benefits.

4. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?

Correct answer: B

Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.

5. During a follow-up visit, a home health nurse notices that a client with a gastrostomy tube, who receives intermittent feedings and medications, has developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea?

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag once every 24 hours with warm water can lead to bacterial growth due to inadequate cleaning, potentially causing diarrhea. Hot water, as in choice B, can also promote bacterial growth, which is not desirable. Changing the feeding bag every 48 hours, like in choice C, is within an acceptable timeframe and is unlikely to be a cause of diarrhea. Adding water to the formula before administration, as in choice D, is a common practice to dilute the formula but is not typically associated with causing diarrhea in this scenario.

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