HESI LPN
Fundamentals HESI
1. A guardian reports that a 4-year-old child is waking up with nightmares. Which of the following interventions should the nurse suggest?
- A. Offer the child a large snack before bedtime.
- B. Allow the child to watch an extra 30 minutes of TV in the evening.
- C. Have the child go to bed at a consistent time every day.
- D. Increase physical activity before bedtime.
Correct answer: C
Rationale: The correct answer is to have the child go to bed at a consistent time every day. Consistent bedtime routines can help reduce nightmares by providing the child with a sense of security and stability. Offering a large snack before bedtime or allowing extra TV time may disrupt sleep patterns and lead to nightmares. Increasing physical activity before bedtime could have the opposite effect and make it harder for the child to fall asleep.
2. When a healthcare professional makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The healthcare professional's attempt to irrigate the tube with 10ml of 0.9% NaCl was unsuccessful, so they determine that the tube was obstructed. Which of the following actions should the healthcare professional take?
- A. Notify the healthcare provider.
- B. Attempt to irrigate the tube with a larger volume of saline.
- C. Replace the NG tube with a new one.
- D. Reposition the client to see if that helps the tube drain.
Correct answer: A
Rationale: If an NG tube is obstructed and cannot be irrigated successfully, notifying the healthcare provider is the appropriate action to take for further management. This is crucial as the healthcare provider may need to assess the situation, provide guidance, or intervene with specific interventions. Attempting to irrigate the tube with a larger volume of saline (Choice B) may exacerbate the situation if the tube is truly obstructed. Replacing the NG tube with a new one (Choice C) should not be the initial action unless advised by the healthcare provider. Repositioning the client (Choice D) may not necessarily resolve the tube obstruction and should not be the primary intervention in this scenario.
3. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?
- A. Thick, tenacious pulmonary secretions
- B. Low-molecular-weight heparin doses
- C. SCDs wrapped around the legs
- D. Elastic stockings (TED hose)
Correct answer: B
Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.
4. A 3-year-old child diagnosed with celiac disease attends a daycare center. Which of the following would be an appropriate snack?
- A. Cheese crackers
- B. Peanut butter sandwich
- C. Potato chips
- D. Vanilla cookies
Correct answer: C
Rationale: The correct answer is potato chips. As a child with celiac disease needs to avoid gluten, potato chips are a suitable snack choice as they are typically gluten-free. Cheese crackers (Choice A) and vanilla cookies (Choice D) contain gluten, which should be avoided by individuals with celiac disease. While peanut butter sandwiches (Choice B) could be gluten-free depending on the bread used, it is not the best choice as cross-contamination is a concern in shared environments like daycare centers.
5. The healthcare provider is caring for a client with tuberculosis (TB). Which type of isolation precautions should the healthcare provider implement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct answer: B
Rationale: When caring for a client with tuberculosis (TB), airborne precautions should be implemented. Tuberculosis is spread through the air via droplet nuclei, requiring the use of airborne precautions to prevent the transmission of the infection. Droplet precautions are used for diseases spread by large respiratory droplets, such as influenza or pertussis. Contact precautions are used for diseases that spread through direct contact, such as MRSA. Standard precautions are used for all clients to prevent the transmission of infections from blood, body fluids, non-intact skin, and mucous membranes.
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