a nurse in a providers office is assessing a client who has heart failure the client has gained weight since her last visit and her ankles are edemato
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

2. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?

Correct answer: D

Rationale: The correct answer is D because in middle adulthood, individuals often shift their focus towards concerns related to the next generations. They reflect on their roles in guiding and supporting the younger generations. Choice A is incorrect as evaluating behavior after a social interaction is more relevant to self-awareness, which is not a specific developmental task for middle adulthood. Choice B, learning to trust others, is more commonly associated with early adulthood tasks related to forming intimate relationships. Choice C, wishing to find meaningful friendships, is more aligned with tasks associated with young adulthood and social connections.

3. The healthcare provider is monitoring a client in active labor. Which pattern on the fetal heart monitor requires immediate intervention?

Correct answer: B

Rationale: Late decelerations are concerning as they indicate uteroplacental insufficiency, potentially resulting in fetal hypoxia. Immediate intervention is necessary to address the underlying cause and ensure fetal well-being. Early decelerations are typically benign and associated with head compression during contractions. Accelerations are reassuring and indicate fetal well-being. Moderate variability is a normal finding and indicates a healthy autonomic nervous system response. Therefore, late decelerations (Choice B) require immediate attention, while the other patterns are generally considered normal or benign during labor.

4. The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?

Correct answer: A

Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).

5. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?

Correct answer: D

Rationale: The correct answer is D because there is no need to wait 72 hours before allowing the child to stand. The synthetic cast does not affect weight-bearing capacity, and standing can be done as tolerated. Choice A is incorrect because keeping the cast covered can lead to damage or accidents. Choice B is acceptable as applying an ice pack can help relieve itching. Choice C is also correct as elevating the cast on pillows can help reduce swelling and promote comfort during rest.

Similar Questions

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan?
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 nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?
A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?

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