HESI LPN FUNDAMENTALS PRACTICE EXAM WITH 100% CORRECT ANSWERS

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? - correct answer Ask the client to relax and run a small amount of fluid into the rectum. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? - correct answer Vitamin B12. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day.What is the best action for the nurse to implement when assisting the client from the bed to the chair? - correct answer Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? - correct answer Combination of plant proteins to provide essential amino acids. A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? - correct answer "It may hurt but we'll give you medicine to help you feel better." When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? - correct answer "What is concerning you this morning?" Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? - correct answer Upon discharge, the client will list three ways to protect the feet from injury. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? - correct answer Cradle the client's heel. While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? - correct answer Instruct the client to take slow deep breaths and stop bearing down. What action should the nurse implement when adding sterile liquids to a sterile field? - correct answer Consider the sterile field contaminated if it becomes wet during the procedure. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? - correct answer Continue the planned nursing interventions to restore the client's fluid volume. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? - correct answer Take measures to promote as much comfort as possible. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - correct answer Draw up the irrigating solution into the syringe. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? - correct answer Reposition the client's arm. What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? - correct answer Check capillary refill of toes on lower extremity with Unna's paste boot. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? - correct answer Wet to moist dressing. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? - correct answer Herbs should be obtained from manufacturers with a history of quality control of their supplements. The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? - correct answer One-inch pressure sore draining serous fluid. The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? - correct answer Refuse to perform the task that is beyond the nurse's experience. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? - correct answer Sensory pattern, area, intensity, and nature of the pain. What action by the nurse demonstrates culturally sensitive care? - correct answer Asks permission before touching a client. A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? - correct answer Inform the family that death is imminent. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? - correct answer Continue gabapentin. When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? - correct answer Flush the lumen with the saline solution and administer the medication through the lumen. How should the nurse handle linens that are soiled with incontinent feces? - correct answer Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? - correct answer Drape the sheets over the footboard of the bed. A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? - correct answer Identify the break in surgical asepsis and provide another set of sterile supplies. The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care? - correct answer Risk for aspiration. In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? - correct answer Document the presence and volume of the pulse palpated. A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? - correct answer "I will ask one of the female nurses to bathe you." Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? - correct answer Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? - correct answer Use reflective listening techniques when the client expresses spiritual doubts. During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? - correct answer Degree of flexion and extension of the client's knee joint. The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? - correct answer Upper torso. An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? - correct answer Rashes in the axillary, groin, and skin fold regions. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? - correct answer Instruct the client that the stoma will become smaller when the initial swelling diminishes. The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? - correct answer Reassess the client's blood pressure using a larger cuff. A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) - correct answer 2 A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? - correct answer Demonstrating the wound care procedure correctly. A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.) - correct answer 2 A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.) - correct answer 2 An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? - correct answer The nurse who transferred the client to the chair when the fall occurred. The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? - correct answer A lactating woman nursing her 3-day-old infant. An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? - correct answer Notify the healthcare provider of the family's request. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? - correct answer Avoid any types of sprays, powders, and perfumes. A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? - correct answer Ensure the accuracy of the blood type match. The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? - correct answer Report the results of the vital signs to the nurse.