HESI LPN
HESI Fundamentals 2023 Quizlet
1. What action should the nurse take to prevent the development of deep vein thrombosis (DVT) in a client who is postoperative day 2 following hip replacement surgery?
- A. Encourage the client to remain on bed rest as much as possible.
- B. Apply sequential compression devices (SCDs) to the client's legs.
- C. Massage the client's legs to improve circulation.
- D. Encourage the client to perform ankle and foot exercises.
Correct answer: B
Rationale: The correct action to prevent DVT in a postoperative client is to apply sequential compression devices (SCDs) to promote venous return. This helps prevent stasis of blood in the lower extremities, reducing the risk of clot formation. Encouraging bed rest (Choice A) may lead to decreased mobility and increase the risk of DVT. Massaging the client's legs (Choice C) is contraindicated in the presence of DVT as it can dislodge a clot. Encouraging ankle and foot exercises (Choice D) may be beneficial for circulation, but SCDs are more effective at preventing DVT in this scenario.
2. The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?
- A. Serum potassium
- B. Blood glucose
- C. Serum sodium
- D. Serum calcium
Correct answer: B
Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.
3. The LPN/LVN is assisting with the care of a client who has just had a liver biopsy. What position should the nurse place the client in immediately following the procedure?
- A. Supine with the right arm raised above the head
- B. Supine with the head of the bed elevated
- C. Right side-lying with a pillow under the costal margin
- D. Left side-lying with the head of the bed flat
Correct answer: C
Rationale: The correct position for a client immediately following a liver biopsy is right side-lying with a pillow under the costal margin. This position helps prevent bleeding by applying pressure to the biopsy site. Placing the client supine with the right arm raised above the head (Choice A) or supine with the head of the bed elevated (Choice B) are not ideal positions for post-liver biopsy care as they do not provide the necessary pressure to the biopsy site. Left side-lying with the head of the bed flat (Choice D) is also not recommended as it does not assist in preventing bleeding after a liver biopsy.
4. The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?
- A. I will reduce my salt intake.
- B. I will exercise for 30 minutes most days of the week.
- C. I will drink alcohol only on the weekends.
- D. I will monitor my blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.
5. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?
- A. Screening groups of older adults in nursing care facilities for early influenza manifestations
- B. Promoting hand hygiene to prevent the spread of influenza
- C. Administering influenza vaccinations
- D. Educating about the importance of healthy lifestyle choices to prevent influenza
Correct answer: A
Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.
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