HESI LPN
HESI Fundamentals Exam
1. The healthcare provider is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the healthcare provider use when reporting to the oncoming shift?
- A. Cheilitis
- B. Halitosis
- C. Glossitis
- D. Dental caries
Correct answer: B
Rationale: The correct term the healthcare provider will use when reporting the extremely bad breath of the unconscious patient to the oncoming shift is 'Halitosis' (Choice B). Halitosis specifically refers to bad breath. Cheilitis (Choice A) is inflammation of the lips, not related to bad breath. Glossitis (Choice C) is inflammation of the tongue, not directly associated with bad breath. Dental caries (Choice D) are cavities in the teeth, which can contribute to bad breath but are not the term used to describe bad breath itself.
2. A healthcare professional is preparing to administer gentamicin 2 mg/kg via IV bolus to a client who weighs 220 lb. How many mg should the healthcare professional administer?
- A. 200 mg
- B. 100 mg
- C. 160 mg
- D. 180 mg
Correct answer: C
Rationale: To calculate the dosage correctly, the weight in pounds must first be converted to kilograms. 220 lb / 2.2 = 100 kg. Then, multiply the weight in kg by the dosage of 2 mg/kg: 2 mg/kg × 100 kg = 200 mg. Therefore, the correct dosage to administer is 200 mg, which is closest to option A. Option C (160 mg) is incorrect because it does not match the calculated dosage. Options B (100 mg) and D (180 mg) are also incorrect as they do not align with the correct calculation.
3. The LPN is caring for a client who has been placed in restraints. What is the most important action for the nurse to take?
- A. Ensure that the client’s circulation is checked every hour.
- B. Document the reason for the restraints every 4 hours.
- C. Provide range-of-motion exercises every 2 hours.
- D. Release the restraints every 2 hours for repositioning.
Correct answer: D
Rationale: The most crucial action for the nurse to take when caring for a client in restraints is to release the restraints every 2 hours for repositioning. This practice helps prevent complications such as pressure ulcers and impaired circulation by ensuring adequate blood flow and preventing skin breakdown. Checking the client's circulation every hour (Choice A) is important, but releasing the restraints for repositioning takes precedence to prevent serious complications. While documenting the reason for restraints (Choice B) is essential for legal and documentation purposes, it is not as critical as providing necessary care to the client's physical well-being. Providing range-of-motion exercises (Choice C) is beneficial for maintaining mobility but may not address the immediate risks associated with prolonged restraint use.
4. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?
- A. Keep the client's bed in the lowest position.
- B. Encourage the client to wear non-slip socks.
- C. Place a fall risk sign on the client's door.
- D. Use a gait belt when ambulating the client.
Correct answer: A
Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.
5. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
- A. Obtain client information
- B. Develop a plan of care
- C. Implement nursing interventions
- D. Evaluate the client's response to treatment
Correct answer: A
Rationale: The correct answer is A: Obtain client information. The first step in the nursing process is assessment, which involves gathering data about the client's condition, needs, and preferences. This information forms the foundation for developing a comprehensive plan of care. Developing a plan of care (Choice B) comes after assessment to address the identified needs. Implementing nursing interventions (Choice C) follows the development of the plan of care. Evaluating the client's response to treatment (Choice D) occurs after implementing the interventions to determine the effectiveness of the care provided. Therefore, the initial and priority step is to obtain client information through assessment.
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