HESI LPN
HESI Fundamentals Study Guide
1. While providing care to a group of patients, which patient should the nurse prioritize seeing first?
- A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
- B. A bedridden patient with a reddened area on the buttocks who needs to be turned
- C. A patient on bed rest with renal calculi who needs to go to the bathroom
- D. A patient post-knee surgery who needs range of motion exercises
Correct answer: A
Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.
2. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct answer: A
Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.
3. During the admission assessment of a terminally ill male client, he states that he is agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement of the client’s spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client’s choice
Correct answer: B
Rationale: The best nursing action in response to a terminally ill client stating their agnostic beliefs is to document the client's spiritual assessment. By documenting this information, the healthcare team can ensure that the client's beliefs are acknowledged and respected in their care plan. Providing information about the chapel's hours or inviting the client to a healing service may not align with the client's beliefs and preferences. Offering to contact a spiritual advisor of the client's choice may not be necessary if the client has clearly stated their agnostic beliefs, as they may not wish to engage in spiritual counseling.
4. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?
- A. Pull down and out at the back of the upper denture to remove.
- B. Brush the dentures with a toothbrush and denture cleaner.
- C. Rinse the dentures with hot water after cleaning them.
- D. Place the dentures in a clean, dry storage container after cleaning them.
Correct answer: B
Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.
5. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain feel like burning or aching?
- C. Is the pain constant or intermittent?
- D. Does the pain feel like throbbing or stabbing?
Correct answer: A
Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.
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