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. What action should be taken to maintain the patency of a peripherally inserted central catheter (PICC)?
- A. Flush the catheter with heparin solution daily.
- B. Change the dressing at the insertion site daily.
- C. Use sterile technique when changing the dressing.
- D. Keep the insertion site dry at all times.
Correct answer: C
Rationale: The correct answer is to use sterile technique when changing the dressing. This practice is essential for preventing infections that can compromise the patency of the PICC line. While flushing the catheter with heparin solution helps prevent clot formation, it does not directly maintain patency. Changing the dressing daily is important for hygiene but does not have a direct impact on catheter patency. Keeping the insertion site dry is crucial to prevent infections but does not specifically address patency maintenance.
3. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct answer: C
Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.
4. 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.
5. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in a Sim's position with the weight on the anterior ilium.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct answer: C
Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.
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