HESI LPN
Fundamentals HESI
1. A client who is malnourished expresses concern about losing their loose wedding ring. What is the most appropriate action for the nurse to take?
- A. I can pin it to your hospital gown to prevent it from falling off.
- B. I will place it in your drawer to keep it safe.
- C. I will hold onto it until a family member can retrieve it.
- D. I can put it in a locked storage unit for you.
Correct answer: D
Rationale: The most appropriate action for the nurse to take is to put the client's wedding ring in a locked storage unit for safekeeping. This ensures that the ring is secure and minimizes the risk of loss or damage. Choices A, B, and C do not provide the same level of security and protection as placing the ring in a locked storage unit. Pinning it to the hospital gown (Choice A) may not be secure and could still lead to loss. Placing it in the client's drawer (Choice B) may not guarantee its safety. Holding onto it until a family member retrieves it (Choice C) leaves the ring vulnerable to misplacement or theft.
2. The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?
- A. Apply a hydrocolloid dressing to the ulcer.
- B. Reposition the client every 2 hours.
- C. Use a donut-shaped cushion when the client is sitting.
- D. Massage the area around the ulcer to promote circulation.
Correct answer: B
Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.
3. During an abdominal assessment for an adult client, what is the correct sequence of steps?
- A. Inspect, Auscultate, Percuss, Palpate
- B. Palpate, Percuss, Inspect, Auscultate
- C. Auscultate, Inspect, Percuss, Palpate
- D. Percuss, Palpate, Inspect, Auscultate
Correct answer: A
Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.
4. A nurse is evaluating a client’s use of a cane. What is the correct use?
- A. Client holds the cane on the stronger side of the body.
- B. Client holds the cane on the weaker side of the body.
- C. Client holds the cane in front of the weaker side of the body.
- D. Client holds the cane in front of the stronger side of the body.
Correct answer: A
Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.
5. During assessment, what is a nurse monitoring when assessing body alignment?
- A. The relationship of one body part to another in different positions
- B. The coordination between musculoskeletal and nervous systems
- C. The force opposing movement direction
- D. The ability to move freely
Correct answer: A
Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.
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