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. The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?
- A. I should take the supplement with milk to increase absorption.
- B. I should expect my stools to turn black while taking this supplement.
- C. I should take the supplement with a full glass of water.
- D. I should take the supplement on an empty stomach.
Correct answer: A
Rationale: Taking an iron supplement with milk can decrease its absorption, indicating a need for further teaching.
3. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?
- A. Place a pad under the client’s head
- B. Hold the client’s limbs tightly to prevent injury
- C. Lift the client into bed with the help of other staff members
- D. Insert a bite block into the client’s mouth
Correct answer: A
Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.
4. When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
- A. Change whichever item is incorrect to the correct information
- B. Use the bracelet and admission form until a replacement is supplied
- C. Notify the admissions office and wait to apply the bracelet
- D. Make a corrected identification bracelet for the client
Correct answer: C
Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.
5. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
- A. Using a cuff that is too small will result in an inaccurately high reading.
- B. Using a cuff that is too large will result in an inaccurately low reading.
- C. The regular size cuff is appropriate for all clients.
- D. You should use a cuff of any size as long as it fits.
Correct answer: A
Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.
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