HESI LPN
Fundamentals of Nursing HESI
1. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?
- A. Call the Poison Control Center as soon as the situation is identified
- B. Empty the child's mouth in any case of possible poisoning
- C. Have the child move minimally if a toxic substance was inhaled
- D. Do not induce vomiting if the poison is a hydrocarbon
Correct answer: B
Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.
2. A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?
- A. Apply the stockings with the creases on the front of the leg.
- B. Apply the stockings while the client's legs are in a dependent position.
- C. Remove the stockings at least once per shift.
- D. Remove the stockings while the client is sitting in a reclining chair.
Correct answer: C
Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.
3. A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
- A. Peripheral pulses
- B. Comfort level
- C. Elimination needs
- D. Skin integrity
Correct answer: A
Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.
4. During the check-up of a 2-month-old infant at a well-baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned infants.
- B. Port wine stains are typically associated with other malformations.
- C. Telangiectatic nevi are normal and will disappear as the baby grows.
- D. The child is too young for surgical removal of these at this time.
Correct answer: C
Rationale: The correct answer is C. Telangiectatic nevi, often referred to as 'stork bites,' are common birthmarks in infants and are considered normal. These birthmarks usually fade and disappear as the child grows older. Choices A, B, and D are incorrect because Mongolian spots are bluish-gray birthmarks commonly found in darker-skinned infants, port wine stains are vascular birthmarks that typically do not disappear, and surgical removal is not recommended for telangiectatic nevi as they usually resolve on their own.
5. A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
- A. Concave thoracic spine posteriorly
- B. Exaggerated lumbar curvature
- C. Concave lumbar spine posteriorly
- D. Exaggerated thoracic curvature
Correct answer: B
Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.
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