HESI LPN
HESI Fundamentals Exam Questions
Question 1 of 5
A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?
Correct Answer: C
Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.
Question 2 of 5
A client with a history of heart failure presents to the clinic with a 2-day history of weight gain, swelling in the legs, and shortness of breath. Which of the following is the most appropriate initial nursing action?
Correct Answer: A
Rationale: Performing a physical assessment is the most appropriate initial nursing action in this scenario. A thorough physical assessment helps evaluate the client's current condition, severity of symptoms, and identify any immediate concerns. This assessment can provide crucial information to guide further interventions and treatment. Reviewing the client's medication list (choice B) is important but may not address the immediate need for assessing the client's current status. Instructing the client to elevate the legs (choice C) may be beneficial but should come after a thorough assessment. Obtaining a detailed dietary history (choice D) is relevant for heart failure management but is not the most urgent initial action when the client presents with acute symptoms like weight gain, leg swelling, and shortness of breath.
Question 3 of 5
The healthcare provider is preparing a client with deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
Correct Answer: D
Rationale: No special preparation is required for a Venous Doppler evaluation. Option A is incorrect because there is no need for the client to be NPO (nothing by mouth) before this test. Option B is incorrect as sedative medication is not typically administered for a Venous Doppler evaluation. Option C is incorrect as discontinuing anticoagulant therapy before the test may not be safe for a client with DVT, as it could increase the risk of developing a blood clot. Therefore, the correct answer is D.
Question 4 of 5
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action:
Correct Answer: A
Rationale: Placing a client in seclusion without proper justification and documentation can lead to charges of unlawful seclusion and restraint, regardless of the client's compliance. This legal issue arises from the potential violation of the client's rights and must be avoided. Choice B is incorrect as the situation does not involve assault and battery. Choice C is incorrect as past violence alone does not justify seclusion without immediate risk. Choice D is incorrect as seclusion should be used based on individual risk and necessity, not solely for maintaining the therapeutic milieu.
Question 5 of 5
A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:
Correct Answer: C
Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.