HESI LPN
HESI Fundamentals Study Guide Questions
Question 1 of 5
A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?
Correct Answer: A
Rationale: Choosing option A, 'Let's talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.
Question 2 of 5
When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?
Correct Answer: A
Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.
Question 3 of 5
When reviewing a client's fluid and electrolyte status, what should the nurse report to the provider?
Correct Answer: A
Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.
Question 4 of 5
Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?
Correct Answer: A
Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.
Question 5 of 5
A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?
Correct Answer: C
Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler's position. Placing the client in Semi-Fowler's or high-Fowler's position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.