the nurse is preparing an elderly client for discharge following treatment for heart failure which statement by the client indicates a need for furthe
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.

2. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement?

Correct answer: D

Rationale: The correct intervention is to give the missed dose at 1300 and adjust the schedule to administer daily at 1300. This approach ensures that the client receives the correct total daily dose of levofloxacin. Choice A is incorrect because contacting the healthcare provider and completing a medication variance form would not address the immediate need to administer the missed dose. Choice B is incorrect as administering the missed dose at 1300 and resuming the 0900 schedule the next morning would result in a missed dose for that day. Choice C is not the best course of action as notifying the charge nurse and completing an incident report should come after addressing the immediate need to administer the missed dose and adjusting the schedule for future doses.

3. After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?

Correct answer: A

Rationale: Observing the rate, depth, and character of the client's respirations is crucial after repositioning a client experiencing shortness of breath. This action provides immediate information about the client's respiratory status. Checking blood pressure (Choice B) is not the priority in this situation, as assessing respirations is more urgent. Assessing the pulse (Choice C) is also important but does not provide direct information about the client's respiratory status. Offering supplemental oxygen (Choice D) may be necessary based on the assessment of respirations, but it should not be the first action taken without assessing the client's breathing pattern.

4. What finding signifies that children have attained the stage of concrete operations according to Piaget?

Correct answer: C

Rationale: The correct answer is C, 'Makes the moral judgment that 'stealing is wrong''. This finding signifies the attainment of the concrete operational stage according to Piaget. At this stage, children begin to understand rules and logic, including moral judgments. Choice A is incorrect because it does not specifically relate to concrete operational thinking. Choice B is incorrect as it refers more to the preoperational stage where children engage in symbolic thought. Choice D is also incorrect as it involves practical reasoning, which is not directly related to the concrete operational stage according to Piaget.

5. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?

Correct answer: A

Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.

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