HESI LPN
HESI Practice Test for Fundamentals
1. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
- A. Using a cuff that is too small will result in an inaccurately high reading.
- B. Using a cuff that is too large will result in an inaccurately low reading.
- C. The regular size cuff is appropriate for all clients.
- D. You should use a cuff of any size as long as it fits.
Correct answer: A
Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.
2. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.” Which of the following responses should the nurse make?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.”
- B. “I’m interested in finding out more about how your body feels to you.”
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.”
- D. “It’s still too soon to expect to feel normal. Give it a little more time.”
Correct answer: B
Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.
3. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
- A. Spaghetti
- B. Watermelon
- C. Chicken
- D. Tomatoes
Correct answer: B
Rationale: The correct answer is 'Watermelon.' Watermelon is high in potassium, which is important to counteract the potassium loss caused by furosemide. Furosemide is a loop diuretic that can lead to potassium depletion, so consuming potassium-rich foods like watermelon can help maintain electrolyte balance. Choices A, C, and D do not specifically address the need for potassium in this scenario and are not as beneficial for addressing the potential electrolyte imbalance caused by furosemide.
4. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
- A. The client reports severe pain
- B. The client asks for a demonstration
- C. The client inquires about potential complications
- D. The client agrees to the procedure
Correct answer: A
Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.
5. A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?
- A. Obtain the pre-transfusion hemoglobin level.
- B. Prime the tubing and set up the blood pump.
- C. Monitor vital signs every 15 minutes for the first hour.
- D. Ensure the accuracy of the blood type match.
Correct answer: D
Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.
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