HESI LPN
HESI Fundamentals Exam Test Bank
1. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?
- A. Hydrocolloid
- B. Gauze
- C. Transparent film
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.
2. A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?
- A. Obtain a thermometer with a short, blunt insertion end
- B. Use the available thermometer as is
- C. Request a new thermometer
- D. Measure the temperature orally instead
Correct answer: A
Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.
3. When preparing an injection for opioid medication, a nurse draws 1mL from a 2mL vial. What should the nurse do next?
- A. Ask another nurse to observe medication wastage
- B. Document the amount of medication drawn on the MAR
- C. Dispose of the remaining medication in a sharps container
- D. Administer the entire vial of medication to avoid wastage
Correct answer: A
Rationale: When drawing medication from a vial, especially for controlled substances like opioids, any wastage must be witnessed by another healthcare professional to ensure accuracy, prevent diversion, and maintain safety standards. This process is crucial for proper documentation and accountability. Recording the amount drawn on the Medication Administration Record (MAR) is important for tracking administered doses and preventing errors. Disposing of the remaining medication in a sharps container is not recommended as it does not address proper wastage documentation. Administering the entire vial of medication just to avoid wastage is inappropriate and can lead to potential harm or overdose in the patient.
4. When preparing to lift and reposition a patient, which action should the nurse take first?
- A. Assess weight to determine assistance needs.
- B. Position a drawsheet under the patient.
- C. Delegate the task to a nursing assistive personnel.
- D. Attempt to manually lift the patient alone before asking for assistance.
Correct answer: A
Rationale: The first action the nurse should take when preparing to lift and reposition a patient is to assess the patient's weight to determine the assistance needed. This step is crucial for the safety of both the patient and the nurse. Positioning a drawsheet under the patient (Choice B) is important for the comfort and safety during the repositioning process but should come after assessing the weight and assistance requirements. Delegating the task to a nursing assistive personnel (Choice C) can be considered once the assessment is complete and additional help is needed. Attempting to manually lift the patient alone before asking for assistance (Choice D) is unsafe and should never be done without first assessing the weight and determining the need for help.
5. A healthcare professional is planning to perform ear irrigation on an adult client with impacted cerumen. Which of the following should the professional plan to take?
- A. Wearing sterile gloves while performing irrigation
- B. Positioning the client with the affected side down following irrigation
- C. Using cool fluid to irrigate the ear canal
- D. Pulling the pinna downward during irrigation
Correct answer: B
Rationale: Positioning the client with the affected side down following irrigation is crucial as it helps facilitate drainage of the dislodged cerumen and any remaining irrigation solution. This position allows gravity to assist in the removal of the loosened debris. Wearing sterile gloves is a standard precaution in healthcare procedures to prevent infection but is not specific to ear irrigation. Using body-temperature water or a solution at a slightly warmer temperature is recommended to prevent vertigo and discomfort, so using cool fluid is incorrect. Pulling the pinna upward and backward, not downward, straightens the ear canal for adults to facilitate the irrigation process, making choice D incorrect.
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