HESI LPN
HESI Fundamentals Practice Questions Questions
Question 1 of 5
When assisting an older adult client with dysphagia following a CVA during mealtime, what should the nurse prioritize?
Correct Answer: B
Rationale: The correct answer is to ensure the client is sitting upright while eating. This position helps prevent aspiration and facilitates swallowing. Offering tart or sour foods (
Choice
A) may not be suitable for someone with dysphagia as they can be difficult to swallow and may increase the risk of aspiration. Providing soft and easily swallowable foods (
Choice
C) is crucial for individuals with swallowing difficulties. While giving thickened liquids (
Choice
D) is a common intervention for dysphagia, the priority during mealtime should be ensuring the client's proper positioning to support safe swallowing and prevent aspiration.
Question 2 of 5
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (
Choice
A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (
Choice
B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (
Choice
D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.
Question 3 of 5
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?
Correct Answer: C
Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice
A) is associated with infection, warmth (choice
B) can indicate phlebitis, and bleeding (choice
D) may occur if the IV catheter punctures a blood vessel.
Question 4 of 5
A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?
Correct Answer: B
Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.
Question 5 of 5
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
Correct Answer: A
Rationale: The correct action to take first when observing blue fingers in a client with wrist restraints is to loosen the right wrist restraint. Blue fingers indicate compromised circulation, and loosening the restraint can help restore blood flow to the area. Applying a pulse oximeter (
Choice
B) or palpating the right radial pulse (
Choice
D) may be necessary following the loosening of the restraint to assess the client's oxygen saturation and pulse. Comparing hand color bilaterally (
Choice
C) is important but not the immediate action needed when a circulation issue is noted in one hand.