HESI LPN
HESI Fundamentals 2023 Quizlet
1. During passive range of motion (ROM) exercises, how should the nurse perform each movement for a patient with impaired mobility?
- A. The nurse moves each movement just to the point of resistance.
- B. The patient repeats each movement 5 times.
- C. The movement continues until the patient reports pain.
- D. The nurse completes each movement quickly and smoothly.
Correct answer: A
Rationale: During passive range of motion (ROM) exercises, the nurse is responsible for moving the patient's joints through their range of motion. The correct technique involves performing movements slowly and smoothly, only going to the point of resistance without causing pain. This technique helps maintain joint flexibility and prevent contractures. Choice A is the correct answer as it reflects the appropriate technique for passive ROM exercises. Choices B and C are incorrect because the patient is not actively participating, and ROM exercises should not cause pain. Choice D is incorrect as movements should be done deliberately and not quickly.
2. When using an open irrigation technique for a client's catheter, what action should the nurse take?
- A. Subtract the amount of irrigant used from the client's urine output.
- B. Add the amount of irrigant used to the urine output measurement.
- C. Measure the amount of irrigant used separately from the urine output.
- D. Document the total amount of fluid used for irrigation only.
Correct answer: A
Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.
3. A nurse manager is overseeing the care on a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
- A. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
- B. A nurse asks a nurse from another unit to assist with her documentation.
- C. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
- D. A nurse discusses a client's status with the physical therapist who is caring for the client at the bedside.
Correct answer: B
Rationale: The correct answer is B. HIPAA guidelines specify that only healthcare professionals directly involved in a patient's care should access their medical information. Asking a nurse from another unit to assist with documentation involves sharing patient information with someone not directly caring for the patient, which violates HIPAA guidelines. Choices A, C, and D involve individuals directly involved in the client's care, making them appropriate actions in line with HIPAA regulations. Choice A involves educating a nursing student under the supervision of the nurse, which is permissible. Choice C involves communicating with the client's designated healthcare decision-maker, which is also allowed under HIPAA. Choice D involves discussing the client's status with another healthcare professional directly involved in the client's care, which is within HIPAA guidelines.
4. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?
- A. Ambulate the client 4 hours after the procedure
- B. Maintain the client on NPO status for 24 hours
- C. Monitor vital signs
- D. Change the dressing every 8 hours
Correct answer: C
Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.
5. When should discharge planning for a client experiencing an exacerbation of heart failure be initiated?
- A. During the admission process
- B. After the client is stabilized
- C. When the client expresses readiness to go home
- D. Just before the expected discharge date
Correct answer: A
Rationale: Discharge planning for a client with an exacerbation of heart failure should begin during the admission process. Initiating discharge planning early ensures a smooth transition and continuity of care for the client. Option B, after the client is stabilized, is not ideal because planning should start early to address potential barriers to discharge. Option C, when the client expresses readiness to go home, may be too late as discharge planning is a proactive process. Option D, just before the expected discharge date, does not allow enough time for comprehensive planning and coordination of post-discharge care needs.
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