HESI LPN
Practice HESI Fundamentals Exam
1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?
- A. Hold the suction catheter with the non-dominant hand.
- B. Apply suctioning for 20 to 30 seconds.
- C. Place the catheter in a clean and dry location for later use.
- D. Use surgical asepsis when performing the procedure.
Correct answer: D
Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.
2. A client is having difficulty breathing while laying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
- A. Suction the client's airway
- B. Administer a bronchodilator
- C. Increase the humidity in the client's room
- D. Assist the client to an upright position
Correct answer: D
Rationale: The correct answer is to assist the client to an upright position. When a client is having difficulty breathing, promoting optimal oxygenation is essential. Elevating the head of the bed improves ventilation and lung expansion by reducing pressure on the diaphragm. This position allows the lungs to expand fully, enhancing oxygen exchange. Suctioning the airway may be necessary if there are secretions causing obstruction, but it is not the first intervention in this scenario. Administering a bronchodilator is appropriate for bronchoconstriction but does not address the immediate need for better ventilation. Increasing humidity can be beneficial in certain respiratory conditions, but it is not the initial priority when a client is struggling to breathe.
3. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
- A. Check the IV tubing for obstruction
- B. Increase the infusion rate
- C. Administer a bolus of fluid
- D. Replace the IV catheter
Correct answer: A
Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.
4. The nurse is teaching a client with newly diagnosed type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?
- A. I will rotate my injection sites to avoid lipodystrophy.
- B. I will check my blood sugar before meals and at bedtime.
- C. I will use the same needle for 3 days if I keep it clean.
- D. I will keep my insulin refrigerated until I need it.
Correct answer: C
Rationale: The correct answer is C because insulin needles should be disposed of after a single use to prevent infection. Reusing the same needle for three days can lead to infection and is not a safe practice. Choices A, B, and D demonstrate good understanding of insulin administration and diabetes management, so they do not indicate a need for further teaching.
5. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct answer: B
Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.
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