HESI LPN
HESI CAT Exam Test Bank
1. When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?
- A. The presence and location of any pressure ulcers.
- B. Measures already taken to maintain client safety.
- C. Any special mattresses on the client’s bed.
- D. Current vital signs and oxygen saturation.
Correct answer: B
Rationale: The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.
2. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
- A. Remind the client of the importance of using a rescue inhaler for asthma management
- B. Leave the client alone to process his thoughts about the inhaler
- C. Ask the client what he is thinking about at that moment
- D. Pause and inquire if the client has any questions or needs clarification
Correct answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.
3. When implementing a disaster intervention plan, which intervention should the nurse implement first?
- A. Initiate the discharge of stable clients from hospital units
- B. Identify a command center where activities are coordinated
- C. Assess community safety needs impacted by the disaster
- D. Instruct all essential off-duty personnel to report to the facility
Correct answer: B
Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.
4. The unlicensed assistive personnel (UAP) has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?
- A. Confirm that the gown is tied securely at the neck and waist
- B. Remind the UAP to wash hands frequently while in the room
- C. Assist the UAP with application of the face mask or face shield
- D. Help the UAP reposition the gown sleeve over the gloves edges
Correct answer: D
Rationale: Proper application of personal protective equipment (PPE) is crucial to maintain infection control. In this scenario, the nurse should help the UAP reposition the gown sleeve over the gloves' edges. This action ensures that the gown properly covers the gloves, reducing the risk of contamination. Choices A, B, and C are incorrect because the primary concern is to address the improper application of PPE by repositioning the gown sleeves over the gloves, not checking other aspects of PPE or reminding about hand hygiene.
5. When washing soiled hands, what should the nurse do after wetting the hands and applying soap?
- A. Rub hands palm to palm
- B. Interlace the fingers
- C. Dry hands with a paper towel
- D. Turn off the water faucet
Correct answer: A
Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.
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