Community Health HESI Test Bank 2023

Questions 55

HESI LPN

HESI LPN Test Bank

Community Health HESI Test Bank 2023 Questions

Question 1 of 5

During the beginning shift assessment of a client with asthma who is receiving oxygen via nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?

Correct Answer: C

Rationale: Rapid, shallow respirations with intermittent wheezes are concerning as they indicate a potential worsening of the client's asthma. This finding suggests airway narrowing, which can lead to respiratory failure. Immediate intervention is required to address this respiratory distress. A pulse oximetry reading of 89% is low and indicates hypoxemia, but the respiratory pattern described in option C takes priority as it directly reflects the client's respiratory status. Crackles at the base of the lungs suggest fluid accumulation, which is important but not as immediately critical as the respiratory distress in asthma. Excessive thirst and a dry cracked tongue may indicate dehydration, which is relevant but not as urgent as the respiratory compromise presented in option C.

Question 2 of 5

The nurse is caring for a 5-year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?

Correct Answer: C

Rationale: Playing handheld games is an appropriate diversional activity for a child in skeletal traction because it does not require physical movement of the affected limb. This activity can help keep the child entertained and engaged without risking any harm to the tractioned leg. Choices A, B, and D involve physical movements that could potentially interfere with the skeletal traction or cause discomfort to the child.

Question 3 of 5

A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

Correct Answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

Question 4 of 5

The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

Correct Answer: D

Rationale: In severe depression, the priority nursing diagnosis is safety. Individuals with severe depression are at risk of self-harm or suicide. Ensuring the client's safety by implementing measures to prevent harm to themselves or others is crucial. While nutrition, elimination, and activity are important aspects of care, ensuring the client's immediate safety takes precedence in this situation.

Question 5 of 5

In a well-child clinic, the nurse examines many children daily. Which of the following toddlers requires further follow-up?

Correct Answer: D

Rationale: The correct answer is D because a 30-month-old should have developed the skill to drink from a regular cup by this age. Drinking from a sip cup at this stage may indicate a delay in development. Choices A, B, and C are not as concerning as they can be within the range of normal development. A 13-month-old not walking yet, a 20-month-old using 2 and 3 word sentences, and a 24-month-old crying during examination are all behaviors that can fall within the spectrum of typical development for their respective ages.

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