HESI LPN
Fundamentals of Nursing HESI
1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?
- A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
- B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
- C. The arms should be crossed over the chest or in the lap.
- D. The feet should be close together with toes pointed out.
Correct answer: A
Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.
2. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?
- A. Confirm unresponsiveness
- B. Check for a pulse
- C. Begin chest compressions
- D. Call for emergency help
Correct answer: A
Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.
3. When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?
- A. Repeat each joint motion five times during each session.
- B. Perform the exercises quickly to save time.
- C. Focus only on the most affected joints.
- D. Assess the client's range of motion before starting.
Correct answer: A
Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.
4. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
- A. Carefully remove the gloves and follow with hand hygiene
- B. Continue with the procedure and clean hands later
- C. Remove the gloves, wash hands, and start over
- D. Use hand sanitizer and continue the procedure
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.
5. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?
- A. Ask the client if he is okay.
- B. Call security from the room.
- C. Find out if there is anyone else in the room.
- D. Ask security to make sure the room is safe.
Correct answer: D
Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.
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