HESI LPN
HESI Practice Test for Fundamentals
1. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:
- A. Positions the irrigating solution bag 30 inches below the stoma
- B. Uses an open system for irrigation
- C. Irrigates the colostomy twice a day
- D. Cleans the stoma with harsh chemicals
Correct answer: A
Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.
2. The nurse is caring for a client with diabetes insipidus. Which finding should the LPN/LVN report to the healthcare provider?
- A. Weight gain
- B. Increased urine output
- C. Low blood pressure
- D. Thirst
Correct answer: B
Rationale: The correct answer is B: Increased urine output. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large amounts of dilute urine. Reporting increased urine output is crucial as it is a hallmark sign of diabetes insipidus. Weight gain (choice A) is not typically associated with diabetes insipidus; instead, clients may experience weight loss due to fluid loss. Low blood pressure (choice C) can be a complication of diabetes insipidus due to dehydration from excessive urination, but the priority finding to report is the increased urine output. Thirst (choice D) is a common symptom of diabetes insipidus due to the body's attempt to compensate for fluid loss, but it is not the most critical finding to report.
3. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glascow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glascow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.
4. A healthcare professional is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the professional assess for?
- A. Loss of bone mass
- B. Loss of strength
- C. Loss of weight
- D. Loss of hope
Correct answer: D
Rationale: Correct. Loss of hope is a significant psychosocial aspect that healthcare professionals should assess for in patients who are immobile. Immobility can lead to feelings of hopelessness and depression, impacting the patient's mental well-being. Assessing for loss of hope allows healthcare professionals to provide appropriate support and interventions to address the patient's emotional needs. Choices A, B, and C are incorrect because they primarily relate to physical changes (bone mass, strength, weight) rather than the psychosocial aspect of hope.
5. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?
- A. Administer nitroglycerin sublingually.
- B. Obtain a 12-lead ECG.
- C. Measure the client's vital signs.
- D. Administer oxygen via nasal cannula.
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.
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