HESI LPN
HESI Fundamentals 2023 Quizlet
1. A client has a new cast on the left arm, and the nurse is assessing the client. Which of the following findings should the nurse report to the provider immediately?
- A. Increased warmth in the affected arm
- B. Itching under the cast
- C. Pain with passive movement
- D. Drainage on the cast
Correct answer: C
Rationale: The correct answer is C: Pain with passive movement. Pain with passive movement in a client with a new cast can indicate compartment syndrome, a serious condition where pressure builds up within the muscles, nerves, and blood vessels of the affected limb, potentially leading to tissue damage. Immediate reporting is crucial to prevent further complications. Increased warmth in the affected arm could be a normal inflammatory response to the injury and casting process. Itching under the cast is common and can be managed without immediate concern. Drainage on the cast may be expected initially after casting due to residual moisture from the setting process, but ongoing or excessive drainage should be monitored and reported if persistent.
2. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?
- A. In the morning upon rising.
- B. Immediately after the client eats breakfast.
- C. Before the client goes to bed.
- D. After the client has had a drink of water.
Correct answer: A
Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.
3. A healthcare provider is caring for a client who has a heart murmur. The healthcare provider is preparing to auscultate the pulmonary valve. Over which of the following locations should the healthcare provider place the bell of the stethoscope?
- A. Second intercostal space at the left sternal border
- B. Fifth intercostal space at the midclavicular line
- C. Fourth intercostal space at the left sternal border
- D. Fifth intercostal space at the left anterior axillary line
Correct answer: A
Rationale: The correct location to auscultate the pulmonary valve is the second intercostal space at the left sternal border. This area is where the pulmonary valve can best be heard due to its anatomical position. Choice B, the fifth intercostal space at the midclavicular line, is the location for auscultating the mitral valve. Choice C, the fourth intercostal space at the left sternal border, is the area for the tricuspid valve. Choice D, the fifth intercostal space at the left anterior axillary line, is the site for listening to the mitral valve as well. Therefore, option A is the correct choice for auscultating the pulmonary valve.
4. A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?
- A. Extinguish the fire.
- B. Activate the fire alarm.
- C. Move clients who are nearby.
- D. Close all open doors on the unit.
Correct answer: B
Rationale: In a fire emergency, the nurse's priority is to activate the fire alarm. This action alerts others to the emergency, initiates the evacuation process, and ensures everyone's safety. Extinguishing the fire can be dangerous and should be left to trained personnel. Moving clients who are nearby might delay the activation of the alarm and can put the nurse and clients at risk. Closing all open doors on the unit is important to contain the fire but should not take precedence over alerting others through the fire alarm system.
5. A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should be administered?
- A. Meperidine 75 mg IM
- B. Fentanyl 50 mcg/hr transdermal patch
- C. Morphine 2 mg IV
- D. Oxycodone 10 mg PO
Correct answer: C
Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.
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