HESI LPN
Fundamentals HESI
1. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication is not an option for managing pain. Which of the following is an appropriate response by the nurse?
- A. I'm sure it will work if you just give it a chance.
- B. You may take any herbal remedies you bring from home.
- C. Why do you think pain medication is not going to help you?
- D. Would you like me to give you a back massage?
Correct answer: D
Rationale: In this scenario, the client has expressed that pain medication is not an option for managing pain. Offering alternative pain relief options like a back massage is appropriate because it respects the client's preferences and provides a non-pharmacological intervention to help alleviate pain. Choices A, B, and C are not as suitable: A may come across as dismissive of the client's decision, B may not be safe as herbal remedies can interact with medical treatments, and C focuses more on questioning the client's decision rather than providing immediate comfort.
2. During an admission history, a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress?
- A. Blood glucose - a common stress response.
- B. Intestinal peristalsis - should decrease due to stress.
- C. Peripheral blood vessels diameter - can vary in response to stress.
- D. Urine output - may vary but not a typical stress response.
Correct answer: A
Rationale: The correct answer is A. Stress typically increases blood glucose levels due to the release of stress hormones like cortisol and adrenaline. Elevated blood glucose helps provide energy for the body to cope with the stressful situation. Choice B is incorrect because intestinal peristalsis, the movement of the intestines, is more likely to decrease under stress due to the 'fight or flight' response. Choice C is incorrect as peripheral blood vessels' diameter may vary in response to stress, with both constriction and dilation possible. Choice D is incorrect as urine output may increase or decrease depending on individual differences and the specific stress response, but it is not a typical or direct physiological response to stress.
3. A healthcare professional is preparing to administer gentamicin 2 mg/kg via IV bolus to a client who weighs 220 lb. How many mg should the healthcare professional administer?
- A. 200 mg
- B. 100 mg
- C. 160 mg
- D. 180 mg
Correct answer: C
Rationale: To calculate the dosage correctly, the weight in pounds must first be converted to kilograms. 220 lb / 2.2 = 100 kg. Then, multiply the weight in kg by the dosage of 2 mg/kg: 2 mg/kg × 100 kg = 200 mg. Therefore, the correct dosage to administer is 200 mg, which is closest to option A. Option C (160 mg) is incorrect because it does not match the calculated dosage. Options B (100 mg) and D (180 mg) are also incorrect as they do not align with the correct calculation.
4. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct answer: B
Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.
5. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
- A. Monitoring evidence-based practice for clients with specific diagnoses.
- B. Ensuring that health care providers comply with regulations.
- C. Setting quality standards for accrediting health care facilities.
- D. Determining the safety of medications for administration to clients.
Correct answer: B
Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).
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