HESI LPN
Fundamentals HESI
1. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?
- A. Drowsiness, lethargy, and inactivity
- B. Dry mouth, nasal congestion, and blurred vision
- C. Rash, blood dyscrasias, severe depression
- D. Hyperglycemia, weight gain, and edema
Correct answer: C
Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.
2. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?
- A. Acne
- B. Warts
- C. Psoriasis
- D. Herpes simplex
Correct answer: D
Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.
3. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Secure the tube to the client's gown.
- C. Check the placement of the tube by auscultation.
- D. Irrigate the tube with normal saline every shift.
Correct answer: A
Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.
4. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.
5. When admitting an older adult client who is Hispanic, which of the following cultural considerations should the nurse include when developing the plan of care?
- A. The Hispanic culture views late adulthood as a time of wisdom and experience
- B. The Hispanic culture expects adult children to care for older adult parents
- C. The Hispanic culture identifies the eldest female family member as the decision maker
- D. The Hispanic culture expects individuals to make their own decisions when death is imminent
Correct answer: B
Rationale: In Hispanic culture, there is an expectation that adult children will care for their older parents, emphasizing a strong family support system. This cultural value highlights the importance of filial piety and respect for elders within the family structure. Choice A is incorrect because Hispanic culture generally values late adulthood as a time of wisdom and experience, not a negative time. Choice C is incorrect as Hispanic culture typically involves collective family decision-making rather than assigning decision-making solely to the eldest female member. Choice D is incorrect as Hispanic culture values family support and involvement in end-of-life decisions rather than individual decision-making.
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