HESI LPN
HESI Fundamentals Exam Test Bank
1. What should be done when caring for a client who died?
- A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
- B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
- C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
- D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.
Correct answer: A
Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.
2. Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?
- A. Oil Retention
- B. Saline
- C. Soapy Water
- D. Hypertonic
Correct answer: A
Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.
3. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?
- A. Complete an incident report
- B. Measure the client’s respiratory rate
- C. Report the incident to the pharmacy
- D. Notify the client's provider
Correct answer: B
Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.
4. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?
- A. Erythema on pressure points
- B. Lower-extremity pulse strength of 2+
- C. Fluid intake of 3,000 mL per day
- D. A bowel movement every other day
Correct answer: A
Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.
5. A middle-aged adult in a clinical setting mentions being at average risk for colon cancer and asks about routine screening. What should the nurse recommend?
- A. Performing a blood sample for a screening test.
- B. Scheduling a colonoscopy starting at age 60.
- C. Undergoing a fecal occult blood test annually.
- D. Having a sigmoidoscopy every 10 years.
Correct answer: C
Rationale: The correct answer is C. Colorectal cancer screening for individuals at average risk typically begins at age 50. One of the recommended options for routine screening is a fecal occult blood test done annually. Choice A is incorrect as blood samples are not used for routine colorectal cancer screening. Choice B is incorrect because colonoscopies usually start at age 50, not 60. Choice D is incorrect as sigmoidoscopies are recommended every 5 years, not every 10 years, for individuals at average risk for colon cancer.
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