ATI LPN
HESI LPN Fundamentals Test Questions
Question 1 of 5
After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?
Correct Answer: D
Rationale: Post-collision with confusion, headache, and drowsiness, monitoring for increased ICP (D) is the priority to detect deterioration. Minimal movement (A) is secondary. Mannitol (B) requires orders. Stimulation (C) may not help. D is correct. Rationale: ICP monitoring identifies progression like hematoma, guiding urgent intervention, per trauma care priorities.
Question 2 of 5
The nurse is caring for a client with a traumatic brain injury who is at risk for seizures. The healthcare provider prescribes phenytoin. Which laboratory value should the nurse monitor while the client is receiving this medication?
Correct Answer: B
Rationale: Phenytoin, an anticonvulsant, requires monitoring liver function tests (B) due to hepatotoxicity risk. Potassium (A), BUN (C), or WBC (D) aren't primary. B is correct. Rationale: Liver metabolism of phenytoin can elevate enzymes, necessitating regular checks, per pharmacology, to prevent toxicity in brain injury care.
Question 3 of 5
You are a student nurse working as a part-time or temporary nursing assistant in a nursing home. The nurse on duty asks you to insert a nasogastric tube in a patient. You have recently passed an examination on putting in a nasogastric tube. Which of the following actions is best on your part?
Correct Answer: D
Rationale: As a student nurse working as a nursing assistant, refusing to insert a nasogastric tube is the best action because it exceeds your legal scope of practice. Nursing assistants, even with training, are not authorized to perform invasive procedures like NG tube insertion, which requires a licensed nurse's skill and accountability. Doing it, even with supervision, risks legal and safety violations, as your role is limited to basic care. Consulting an instructor delays action and doesn't resolve the legal issue. Informing the nurse of your limitation upholds professional boundaries, protects the patient from potential harm due to inexperience, and ensures compliance with regulations, prioritizing safety and legality over task completion.
Question 4 of 5
When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
Correct Answer: D
Rationale: Using a quick-release knot to secure a vest restraint ensures safety by allowing rapid removal in emergencies, like respiratory distress. Tying to side rails or movable frames risks injury if the bed adjusts, and square knots are hard to undo quickly. Quick-release knots comply with safety standards, balancing restraint necessity with the ability to free the client swiftly, a critical consideration in nursing to prevent harm while managing behavior.
Question 5 of 5
In the Problem Oriented Medical Record documentation system (POMR), which of the following answers best represents the person or persons who may contribute to the problem list representing the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs?
Correct Answer: D
Rationale: In POMR, all caregivers contribute to the problem list, reflecting a holistic view of the client's needs across domains. This interdisciplinary input from nurses, physicians, social workers ensures comprehensive care, like noting spiritual distress alongside physical issues. Limiting to specific roles misses diverse perspectives, a strength of this system in nursing documentation.