HESI LPN
HESI Fundamentals Exam
1. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- A. Educating clients about the recommended immunization schedule for adults
- B. Teaching clients how to manage chronic illnesses
- C. Providing counseling for depression
- D. Offering support groups for cancer survivors
Correct answer: A
Rationale: The correct answer is A: Educating clients about the recommended immunization schedule for adults. This activity falls under primary prevention, which aims to prevent the onset of illness or injury. Immunizations are a proactive measure to protect individuals from developing certain diseases. Choices B, C, and D involve managing chronic illnesses, providing counseling for mental health issues, and offering support for individuals who have already experienced cancer, respectively. These activities are more aligned with secondary or tertiary prevention, focusing on managing existing conditions or preventing complications in those already affected.
2. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
- A. Dissolve each medication in 5 mL of sterile water.
- B. Draw up each medication separately in the syringe.
- C. Push the syringe plunger gently if feeling resistance.
- D. Flush the tube with 15 mL of sterile water.
Correct answer: D
Rationale: The correct action the nurse should take when administering multiple medications to a client with an enteral feeding tube is to flush the tube with 15-30 mL of sterile water before and between medications, and 30-60 mL after the last medication. This helps prevent clogging and ensures each medication is delivered effectively. Choice A is incorrect as medications should not be dissolved in water for administration through an enteral feeding tube. Choice B is incorrect because each medication should be drawn up and administered separately to prevent any potential interactions. Choice C is incorrect as resistance while pushing the plunger may indicate a problem that needs to be addressed before continuing with the administration.
3. A client with chronic back pain asks a nurse about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?
- A. Obesity
- B. Hypertension
- C. Migraines
- D. Cellulitis
Correct answer: D
Rationale: The correct answer is D, Cellulitis. Cellulitis is a contraindication for acupuncture due to the risk of infection. Acupuncture involves inserting needles into the skin, and if a person has cellulitis, which is a bacterial skin infection, there is a higher risk of introducing the infection deeper into the body. Obesity (choice A), hypertension (choice B), and migraines (choice C) are not contraindications for receiving acupuncture. These conditions do not pose a direct risk of complications related to acupuncture treatment.
4. While documenting in a client’s medical record, which of the following entries should the nurse record?
- A. “Incision without redness or drainage”
- B. “Drank adequate amounts of fluid with meals”
- C. “Administered pain medication”
- D. “Oral temperature slightly elevated at 0800”
Correct answer: D
Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.
5. While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?
- A. Allow the client to slide down their outstretched leg.
- B. Place their arms around the client to prevent the fall.
- C. Remain upright as the client falls toward them.
- D. Move quickly to a position in front of the client.
Correct answer: A
Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.
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