HESI LPN
HESI Fundamentals Exam
1. A 10-year-old client is recovering from a splenectomy following a traumatic injury. The client's laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to:
- A. Limit milk and milk products
- B. Encourage bed rest and quiet activities
- C. Plan nursing care around lengthy rest periods
- D. Promote a diet rich in iron
Correct answer: C
Rationale: Encouraging bed rest and quiet activities is crucial for a child recovering from a splenectomy with low hemoglobin and hematocrit levels. This approach helps conserve energy, promotes healing, and allows the body to focus on rebuilding red blood cells. Limiting milk and milk products (Choice A) is not directly related to improving the child's condition. Encouraging bed rest and quiet activities (Choice B) is appropriate as it helps in conserving energy and preventing physical exertion. Promoting a diet rich in iron (Choice D) is beneficial for improving hemoglobin levels in the long term, but immediate rest and recovery take precedence in this scenario.
2. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?
- A. An infant with intermittent bulging anterior fontanel between crying episodes
- B. A toddler with severe deep abrasions covering over 98% of the body
- C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
- D. A school-age child with singed eyebrows and hair on the arms
Correct answer: B
Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.
3. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?
- A. I will take my warfarin at the same time every day.
- B. I should use a soft-bristled toothbrush while taking this medication.
- C. I should take my warfarin at bedtime.
- D. I should avoid eating foods high in vitamin K while taking this medication.
Correct answer: A
Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.
4. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?
- A. Notify the provider about the client's decision
- B. Proceed with the transport
- C. Prepare the surgical site
- D. Document the client’s statement
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.
5. A client has pharyngeal diphtheria. What transmission precautions are necessary?
- A. Droplet
- B. Contact
- C. Airborne
- D. Standard
Correct answer: A
Rationale: Pharyngeal diphtheria is primarily spread through droplet transmission, which occurs when an infected person coughs, sneezes, or talks, releasing respiratory droplets containing the bacteria. Therefore, the correct precaution for caring for a client with pharyngeal diphtheria is droplet precautions. Droplet precautions help prevent the transmission of respiratory pathogens over short distances via respiratory droplets. Contact precautions are used for diseases spread through direct or indirect contact with the patient or their environment. Airborne precautions are used for diseases that spread through small droplets suspended in the air. Standard precautions are basic infection prevention practices applying to all patient care.
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