HESI LPN
HESI Fundamentals 2023 Quizlet
1. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client’s BP.
Correct answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
2. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?
- A. “Get up and change positions slowly.”
- B. “Avoid eating aged cheese and smoked meat.”
- C. “Report any unusual bruising or bleeding to the doctor immediately.”
- D. “Eat the same amount of foods that contain vitamin K every day.”
Correct answer: A
Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.
3. A client has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
- A. Wear gloves when changing the client's gown.
- B. Use hand sanitizer after contact with the client.
- C. Wear a mask when entering the client's room.
- D. Clean the room with a disinfectant spray.
Correct answer: A
Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile in contact isolation is to wear gloves when changing the client's gown. Clostridium difficile is highly transmissible, and wearing gloves helps prevent the spread of the infection. Using hand sanitizer after contact with the client (Choice B) is not enough to prevent the transmission of C. difficile, as the spores can persist and spread. Wearing a mask when entering the client's room (Choice C) is not necessary for C. difficile transmission, which primarily occurs through contact with contaminated surfaces. Cleaning the room with a disinfectant spray (Choice D) is important, but wearing gloves during direct care is the priority to prevent the nurse from acquiring and spreading the infection.
4. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?
- A. Bag bath
- B. Sponge bath
- C. Partial bed bath
- D. Complete bed bath
Correct answer: C
Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.
5. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?
- A. Thread the IV catheter so that the hub rests at the insertion site
- B. Shave excess hair from around the insertion site
- C. Cleanse the site with hydrogen peroxide before IV catheter insertion
- D. Palpate the site carefully just before inserting the IV catheter
Correct answer: A
Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.
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