HESI LPN
HESI Fundamentals Study Guide
1. A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
- A. Administer analgesics to the child on a routine schedule throughout the day and night.
- B. Offer fluids to the child immediately after surgery.
- C. Allow the child to return to solid foods gradually.
- D. Avoid administering any medication until the child is fully awake.
Correct answer: A
Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.
2. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- A. Wear cotton clothing to avoid static electricity.
- B. Avoid using any electrical appliances.
- C. Keep the oxygen tank away from heat sources.
- D. Use only a specific type of nasal cannula.
Correct answer: A
Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.
3. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.
4. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?
- A. Use a 25-gauge needle.
- B. Select a site on the client’s abdomen.
- C. Use the Z-track technique to displace the skin on the injection site.
- D. Observe for bleb formation to confirm proper placement.
Correct answer: B
Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.
5. A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?
- A. Let’s talk about how the change in your job status will affect you.
- B. Have you considered the financial implications of retirement?
- C. What are your thoughts on retirement and how it may impact your life?
- D. Would you like to discuss potential activities you could engage in during retirement?
Correct answer: A
Rationale: Choosing option A, 'Let’s talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99