Fundamentals of Nursing HESI

Fundamentals of Nursing HESI Related

Review Fundamentals of Nursing HESI related questions and content

A client with a history of peptic ulcer disease reports black, tarry stools. What is the most appropriate action for the LPN/LVN to take?

  • A. Reassure the client that this is not a normal finding.
  • B. Notify the healthcare provider immediately.
  • C. Document the finding in the client's chart.
  • D. Encourage the client to seek medical attention.
Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. Black, tarry stools can be indicative of gastrointestinal bleeding, a serious complication that requires urgent medical evaluation and intervention. This finding should not be dismissed or considered normal without further assessment. Option A is incorrect because black, tarry stools are not a normal finding and may signify a significant health issue. Option C is incorrect as immediate action is needed rather than just documenting the finding. Option D is not the best choice as it simply suggests seeking medical attention without emphasizing the urgency of the situation. Prompt notification of the healthcare provider is crucial to ensure timely intervention and management of potential gastrointestinal bleeding.

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Which of the following manifestations confirms the presence of pediculosis capitis in students?

  • A. Scratching the head more than usual
  • B. Flakes evident on a student's shoulders
  • C. Oval pattern occipital hair loss
  • D. Whitish oval specks sticking to the hair
Correct Answer: D

Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.

The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?

  • A. Shortness of breath on exertion
  • B. Weight gain of 2 pounds in a week
  • C. Orthopnea
  • D. Crackles in the lungs
Correct Answer: D

Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.

A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

  • A. Droplet
  • B. Contact
  • C. Airborne
  • D. Protective
Correct Answer: A

Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement?

  • A. Obtain the pre-transfusion hemoglobin level.
  • B. Prime the tubing and set up the blood pump.
  • C. Monitor vital signs every 15 minutes for the first hour.
  • D. Ensure the accuracy of the blood type match.
Correct Answer: D

Rationale: Ensuring the accuracy of the blood type match is crucial to prevent transfusion reactions. The LPN/LVN must prioritize this step to avoid adverse outcomes. Obtaining the pre-transfusion hemoglobin level (Option A) is important but not as critical as ensuring blood type compatibility. Priming the tubing and setting up the blood pump (Option B) and monitoring vital signs every 15 minutes (Option C) are essential steps in the transfusion process, but the primary concern should be preventing transfusion reactions by verifying blood type compatibility.

A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?

  • A. Hypoglycemia
  • B. Hyperglycemia
  • C. Hypertension
  • D. Hyperkalemia
Correct Answer: B

Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.

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