ATI LPN
HESI LPN Fundamentals Test Questions
Question 1 of 5
The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema?
Correct Answer: A
Rationale: Post-pneumonectomy, frothy sputum (A) signals acute pulmonary edema, a fluid overload complication. Pain (B) is surgical. Chest tube drainage (C) isn't present post-pneumonectomy. Rate of 20 (D) is normal. A is correct. Rationale: Frothy sputum reflects alveolar fluid, requiring urgent intervention, per post-surgical monitoring standards.
Question 2 of 5
A client who was in a motorbike accident has a severe neck injury. Which priority nursing care is most needed?
Correct Answer: C
Rationale: Severe neck injury from a motorbike accident prioritizes maintaining a patent airway (C), as trauma may obstruct breathing. Crepitus (A), bleeding (B), and neuro checks (D) follow. C is correct. Rationale: Airway patency is the first ABC step in trauma, preventing hypoxia, per emergency care protocols, critical in neck injuries with potential swelling or fracture.
Question 3 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 4 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 5 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.