HESI LPN
Fundamentals of Nursing HESI
1. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?
- A. Make sure two fingers can fit under the sleeve.
- B. Apply the sleeve tightly to prevent blood clots.
- C. Ensure the sleeve is snug and comfortable.
- D. Check that the sleeve is loose enough to avoid constriction.
Correct answer: A
Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.
2. 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.
3. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will take my medication at the same time every day.
- C. I will use a soft toothbrush to prevent gum bleeding.
- D. I can take aspirin if I have a headache.
Correct answer: D
Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.
4. What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?
- A. Demonstration of appropriate hand hygiene
- B. Explanation of wound care technique
- C. Review of signs and symptoms of infection
- D. Instructions for when to contact the healthcare provider
Correct answer: A
Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.
5. A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?
- A. Fresh fruits
- B. Grilled chicken
- C. Whole grain bread
- D. Canned soup
Correct answer: D
Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.
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