HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
- A. Cheddar cheese
- B. White rice
- C. Apples
- D. Green beans
Correct answer: A
Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.
2. A nurse is planning strategies to manage time effectively for client care. What should the nurse implement?
- A. Use the planning step of the nursing process to prioritize client care delivery.
- B. Delegate all tasks to assistive personnel.
- C. Focus on completing tasks in the order they are assigned.
- D. Avoid using a checklist for daily tasks.
Correct answer: A
Rationale: The correct answer is A. Using the planning step of the nursing process to prioritize client care delivery is crucial for effective time management. By prioritizing tasks based on client needs and acuity levels, the nurse can ensure that the most critical care is provided in a timely manner. Choice B is incorrect because while delegation is important, not all tasks can be delegated, and the nurse is ultimately responsible for the care provided. Choice C is incorrect as completing tasks in the order they are assigned may not align with the urgency of client needs. Choice D is incorrect as using a checklist can help the nurse stay organized and ensure that all necessary tasks are completed.
3. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?
- A. Not offering a backrub to a patient with fractured ribs
- B. Not offering to wash the hair of a patient with neck trauma
- C. Turning off the television while giving a backrub to the patient
- D. Turning the patient's head with neck injury to the side when giving oral care
Correct answer: D
Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.
4. A middle-aged adult in a clinical setting mentions being at average risk for colon cancer and asks about routine screening. What should the nurse recommend?
- A. Performing a blood sample for a screening test.
- B. Scheduling a colonoscopy starting at age 60.
- C. Undergoing a fecal occult blood test annually.
- D. Having a sigmoidoscopy every 10 years.
Correct answer: C
Rationale: The correct answer is C. Colorectal cancer screening for individuals at average risk typically begins at age 50. One of the recommended options for routine screening is a fecal occult blood test done annually. Choice A is incorrect as blood samples are not used for routine colorectal cancer screening. Choice B is incorrect because colonoscopies usually start at age 50, not 60. Choice D is incorrect as sigmoidoscopies are recommended every 5 years, not every 10 years, for individuals at average risk for colon cancer.
5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glascow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glascow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.
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