HESI LPN
HESI Practice Test for Fundamentals Questions
Question 1 of 5
The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?
Correct Answer: B
Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants.
Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (
Choice
A) may indicate respiratory issues, SCDs (
Choice
C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (
Choice
D) are used for DVT prophylaxis but do not alert to hemorrhage.
Question 2 of 5
A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
Correct Answer: A
Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement.
Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job.
Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings.
Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.
Question 3 of 5
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?
Correct Answer: D
Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security.
Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use.
Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client.
Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.
Question 4 of 5
The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?
Correct Answer: A
Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (
Choice
B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (
Choice
C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (
Choice
D) is also not a typical manifestation of myasthenia gravis.
Therefore, the correct answer is muscle weakness (
Choice
A).
Question 5 of 5
A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?
Correct Answer: A
Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (
Choice
B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (
Choice
C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (
Choice
D) is contraindicated and can lead to discomfort and potential injury to the client.