HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hours at a time
- B. Apply an ice pack to the client’s back for 1 hour
- C. Remove distractions from the client’s room
- D. Instruct the client to take deep, rhythmic breaths
Correct answer: D
Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.
2. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
- A. A report of 10 pounds weight loss in the last month
- B. A comment by the client 'I just can't sit still.'
- C. The appearance of eyeballs that appear to 'pop' out of the client's eye sockets
- D. A report of the sudden onset of irritability in the past 2 weeks
Correct answer: C
Rationale: The appearance of eyeballs that appear to 'pop' out of the client's eye sockets, known as exophthalmos, requires quick intervention as it is a severe symptom of Graves' disease. Exophthalmos can indicate an acute condition and may lead to serious complications such as optic nerve damage or corneal ulceration. Weight loss, restlessness, and irritability are common manifestations of hyperthyroidism but do not pose immediate risks compared to the ocular complications associated with exophthalmos.
3. During assessment, what is an indication of thrombophlebitis in a client who has been on bed rest for the past month?
- A. Calf swelling
- B. Elevated blood pressure
- C. Decreased urine output
- D. Generalized rash
Correct answer: A
Rationale: Calf swelling is a common sign of thrombophlebitis, which is inflammation of a vein due to a blood clot. Prolonged immobility can predispose individuals to thrombophlebitis. Calf swelling occurs due to the obstruction of blood flow, causing localized edema. This condition can lead to serious complications like pulmonary embolism if not promptly addressed. Elevated blood pressure, decreased urine output, and a generalized rash are not typically associated with thrombophlebitis. Elevated blood pressure may be linked to other conditions like hypertension, decreased urine output to kidney dysfunction, and a generalized rash to allergic reactions or skin conditions. Therefore, in a client on bed rest, calf swelling should raise suspicion of thrombophlebitis and prompt further evaluation and intervention.
4. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct answer: C
Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.
5. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
- A. Immediately after exhalation.
- B. During the inhalation.
- C. At the end of three inhalations.
- D. Immediately after inhalation.
Correct answer: B
Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI LPN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access