HESI LPN
HESI Fundamentals 2023 Quizlet
1. The healthcare professional is caring for a client with a chest tube. Which observation requires immediate intervention?
- A. Constant bubbling in the suction control chamber
- B. Intermittent bubbling in the water seal chamber
- C. Drainage of 50 ml per hour
- D. Crepitus around the insertion site
Correct answer: D
Rationale: Crepitus around the chest tube insertion site may indicate subcutaneous emphysema, which requires immediate attention. The presence of crepitus suggests air leaking into the tissues, which could lead to respiratory compromise. Constant bubbling in the suction control chamber is expected and indicates proper functioning of the chest tube system. Intermittent bubbling in the water seal chamber is also normal, showing the system is intact. Drainage of 50 ml per hour is within the expected range for a chest tube.
2. A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position
- B. Increase the client's intake of carbohydrates
- C. Massage the reddened areas with unscented lotion
- D. Have the client use a trapeze bar when changing positions
Correct answer: D
Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.
3. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove the needle after discarding used syringes
- B. Wear gloves while disposing of the needle and syringe
- C. Wear a face mask during medication administration
- D. Wash hands before handling the needle and syringe
Correct answer: D
Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.
4. The client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the healthcare provider monitor closely?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Magnesium
Correct answer: A
Rationale: Correct! When a client is taking furosemide (Lasix), monitoring potassium levels is crucial due to the potential for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Low potassium levels can predispose the client to cardiac dysrhythmias. Sodium, calcium, and magnesium levels are not typically affected by furosemide to the same extent as potassium, making them less critical to monitor in this scenario.
5. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
- A. Second intercostal space to the right of the sternum
- B. Fifth intercostal space at the midclavicular line
- C. Left sternal border
- D. Fifth intercostal space at the anterior axillary line
Correct answer: B
Rationale: The correct placement to auscultate the aortic valve is at the second intercostal space to the right of the sternum, which coincides with the aortic area. The choice stating 'Fifth intercostal space at the midclavicular line' is the correct answer for auscultating the aortic valve. Placing the stethoscope at the left sternal border would be more suitable for listening to the tricuspid valve. The fifth intercostal space at the anterior axillary line is the recommended area for auscultating the mitral valve. Therefore, choice B is the correct answer for assessing the aortic valve in a client with a history of a heart murmur related to aortic valve stenosis.
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