HESI LPN
HESI Fundamentals Exam
1. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct answer: B
Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.
2. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?
- A. Apply the cuff above the client's antecubital fossa.
- B. Use a cuff with a width that is about 60% of the client's arm circumference.
- C. Have the client sit with their arm resting at the level of their heart.
- D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.
Correct answer: A
Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.
3. A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?
- A. 8 oz of ice chips
- B. 8 oz of ice chips
- C. 1 cup of broth
- D. 1 cup of broth
Correct answer: A
Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.
4. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?
- A. Hand rolls
- B. A foot cradle
- C. A trapeze bar
- D. A trochanter roll
Correct answer: B
Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.
5. A client with rheumatoid arthritis is prescribed prednisone. What information should the LPN/LVN include when teaching the client about this medication?
- A. Take the medication with food to minimize gastrointestinal side effects.
- B. Avoid exposure to sunlight while taking this medication.
- C. Do not discontinue the medication abruptly.
- D. Increase fluid intake while taking this medication.
Correct answer: C
Rationale: The correct answer is C: 'Do not discontinue the medication abruptly.' It is crucial for clients prescribed prednisone to not stop the medication suddenly to prevent adrenal insufficiency, as this medication suppresses the body's natural production of cortisol. Choice A is incorrect because prednisone should be taken with food to minimize gastrointestinal side effects, not necessarily to prevent stomach upset. Choice B is incorrect as there is no specific need to avoid sunlight while taking prednisone. Choice D is not directly related to prednisone use; while adequate fluid intake is generally beneficial, it is not a specific instruction for prednisone administration.
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