HESI LPN
Fundamentals HESI
1. A client has a sodium level of 125. What findings should the nurse expect?
- A. Abdominal cramping
- B. Elevated blood pressure
- C. Decreased heart rate
- D. Increased thirst
Correct answer: A
Rationale: Low sodium levels (hyponatremia) often present with various symptoms, including abdominal cramping. Abdominal cramping is a common manifestation of hyponatremia due to the altered electrolyte balance. Option B ('Elevated blood pressure') is incorrect because low sodium levels typically lead to decreased blood pressure, not elevated. Option C ('Decreased heart rate') is incorrect as low sodium levels are more likely to cause an irregular heart rate rather than a decreased heart rate. Option D ('Increased thirst') is incorrect because excessive thirst is more commonly associated with high sodium levels (hypernatremia) rather than low sodium levels.
2. When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?
- A. Bend at the waist
- B. Keep feet close together
- C. Use back muscles for lifting
- D. Stand close to the cabinet when lifting it
Correct answer: D
Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.
3. A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin in the same body area each time.
- B. Store the insulin according to the manufacturer's instructions.
- C. Rotate injection sites within the same body area.
- D. Inject the insulin at a 45-degree angle.
Correct answer: C
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.
4. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?
- A. Administer pain medication 45 minutes prior to dressing change.
- B. Change the dressing quickly to minimize pain.
- C. Provide reassurance to the client that the pain will pass.
- D. Use a less painful dressing technique.
Correct answer: A
Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.
5. While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement?
- A. Acknowledge that she is supporting the arm correctly.
- B. Encourage her to keep the joint covered to maintain warmth.
- C. Reinforce the need to grip directly under the joint for better support.
- D. Instruct her to grip directly over the joint for better motion.
Correct answer: A
Rationale: Acknowledging that the client's wife is supporting the arm correctly is the appropriate nursing action in this scenario. By doing so, the nurse reinforces correct technique and promotes confidence. Choice B is incorrect as the issue is not about maintaining warmth. Choice C is incorrect as gripping directly under the joint is not necessary in this case. Choice D is incorrect as instructing to grip directly over the joint may not provide the best support for passive range-of-motion exercises.
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