HESI LPN
Fundamentals HESI
1. The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?
- A. Spinach
- B. Bananas
- C. Chicken
- D. Rice
Correct answer: A
Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.
2. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
3. When providing mouth care for an unconscious client, what action should the nurse take?
- A. Turn the client’s head to the side.
- B. Place two fingers in the client’s mouth to open it.
- C. Brush the client’s teeth once per day.
- D. Inject mouth rinse into the center of the client’s mouth.
Correct answer: A
Rationale: When providing mouth care for an unconscious client, the nurse should turn the client’s head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client’s mouth can be dangerous and may cause injury. Brushing the client’s teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client’s head to the side.
4. The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to
- A. Approach the healthcare provider and staff nurse for a private meeting to address the situation.
- B. Allow the staff nurse to handle this situation without interference.
- C. Notify other administrative personnel of a breach of professional conduct.
- D. Request an immediate private meeting with the healthcare provider and staff nurse.
Correct answer: D
Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.
5. A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
- A. 8 mL/hr
- B. 10 mL/hr
- C. 12 mL/hr
- D. 15 mL/hr
Correct answer: A
Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) × Volume. In this case, it would be (800 units/hr / 25,000 units) × 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.
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