HESI LPN
Fundamentals HESI
1. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer?
- A. 1 ml.
- B. 1.5 ml.
- C. 1.75 ml.
- D. 2 ml.
Correct answer: B
Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.
2. A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?
- A. Assess the client for orthostatic hypotension
- B. Obtain a gait belt
- C. Ensure the client has proper footwear
- D. Ask the client to perform range-of-motion exercises
Correct answer: A
Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.
3. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?
- A. 100% oxygen via partial rebreathing mask
- B. 2 liters per minute via nasal cannula
- C. 4 liters per minute via simple mask
- D. 6 liters per minute via face mask
Correct answer: A
Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.
4. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?
- A. Tops of the ears
- B. Bridge of the nose
- C. Around the nostrils
- D. Over the cheeks
Correct answer: A
Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.
5. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
- A. Infuse normal saline at a keep-vein-open rate.
- B. Discontinue the IV and flush the port with heparin.
- C. Infuse 10% dextrose and water at 54 ml/hr.
- D. Obtain a stat blood glucose level and notify the healthcare provider.
Correct answer: C
Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.
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