HESI LPN
HESI Fundamentals 2023 Test Bank
1. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?
- A. Empty the drainage bag at least every 8 hours
- B. Keep the drainage bag below the level of the bladder
- C. Use sterile technique to collect a specimen from the drainage system
- D. Secure the catheter to the lower abdomen with a securement device
Correct answer: B
Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).
2. A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Request a consultation with the ethics committee
- D. Ask the client's family to intervene
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to withhold the blood transfusion. The principle of autonomy ensures that a competent client has the right to refuse treatment, even if their decision conflicts with the wishes of their partner or family. Asking the client to consider a direct donation (Choice A) is not appropriate as it disregards the client's autonomy and religious beliefs. Requesting a consultation with the ethics committee (Choice C) may be considered in complex ethical dilemmas, but in this case, the client's autonomy should be respected first. Asking the client's family to intervene (Choice D) is not appropriate as the client has the right to make their own healthcare decisions based on their religious beliefs.
3. A client with a diagnosis of myocardial infarction (MI) is being treated. Which laboratory value would be most concerning?
- A. Troponin level of 0.5 ng/mL
- B. Creatine kinase-MB (CK-MB) of 5.0 ng/mL
- C. Serum potassium of 4.5 mEq/L
- D. Blood glucose of 180 mg/dL
Correct answer: A
Rationale: A troponin level of 0.5 ng/mL is elevated, indicating myocardial damage, making it the most concerning finding in a client with a myocardial infarction (MI). Troponin is a highly specific marker for cardiac muscle damage, and elevated levels suggest ongoing injury to the heart muscle. While Creatine kinase-MB (CK-MB) is also a cardiac enzyme, troponin is more specific and sensitive for myocardial damage. Serum potassium and blood glucose levels are important parameters to monitor in MI patients, but in this scenario, the elevated troponin level takes precedence as it directly reflects cardiac injury.
4. An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.†Which of the following is an appropriate nursing response?
- A. You should comply with the request
- B. You seem worried. Are you concerned someone may see you without your teeth?
- C. I will call your family to discuss this
- D. It’s not a big deal; just remove them
Correct answer: B
Rationale: The appropriate nursing response in this situation is to acknowledge and address the client's concerns empathetically. By expressing understanding and asking if the client is worried about being seen without their teeth, the nurse shows empathy and attempts to alleviate the client's anxiety. Choice A is incorrect as it dismisses the client's feelings. Choice C is inappropriate as it does not directly address the client's agitation. Choice D is not the best response as it minimizes the client's feelings and does not provide emotional support.
5. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
- A. Surgery removes the disk and is the only treatment that can totally resolve the pain
- B. The medication regimen you previously used should be re-evaluated for dose adjustment
- C. Massage and hot pack treatments are less invasive and can provide temporary relief
- D. Acupuncture is a complementary therapy that is often effective for management of pain
Correct answer: D
Rationale: Acupuncture has been effective for the client previously, supporting continued use.
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