HESI LPN
HESI Fundamentals Exam Questions
Question 1 of 5
A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.
Question 2 of 5
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?
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.
Question 3 of 5
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?
Correct Answer: A
Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.
Question 4 of 5
A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment.
Therefore, the correct choice is to provide a private room and limit stimulation (option
C) in this scenario.
Question 5 of 5
A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?
Correct Answer: A
Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (
Choice
B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (
Choice
C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (
Choice
D) may overlook a potentially serious cardiac issue that requires immediate attention.