HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is assessing a patient's skin. Which patient is most at risk for impaired skin integrity?
- A. A patient who is afebrile
- B. A patient who is diaphoretic
- C. A patient with strong pedal pulses
- D. A patient with adequate skin turgor
Correct answer: B
Rationale: Excessive moisture on the skin, as seen in a diaphoretic patient, can lead to impaired skin integrity. Diaphoresis softens epidermal cells, promotes bacterial growth, and can cause skin maceration. Afebrile status, strong pedal pulses, and adequate skin turgor are not directly associated with an increased risk of impaired skin integrity. Afebrile indicates the absence of fever, not a risk to skin integrity. Strong pedal pulses suggest good circulation, which is beneficial for skin health. Adequate skin turgor is a sign of good hydration and skin elasticity, indicating a lower risk of impaired skin integrity.
2. A healthcare professional is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Inject the medication into the muscle.
- D. Pinch the skin before injecting.
Correct answer: B
Rationale: Enoxaparin is a medication that is administered subcutaneously, which means it should be injected into the fatty tissue layer beneath the skin. Administering enoxaparin at a 90-degree angle ensures proper absorption and reduces the risk of injecting the medication into muscle tissue, which could affect its effectiveness. Injecting the medication at a 45-degree angle may lead to improper absorption as it may not reach the subcutaneous tissue adequately. Injecting the medication into the muscle instead of subcutaneously can alter the absorption rate and therapeutic effects. Pinching the skin before injecting is not necessary for administering enoxaparin subcutaneously and may cause unnecessary discomfort to the client.
3. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?
- A. Potassium 5.4
- B. Sodium 140
- C. Calcium 8.6
- D. Magnesium 2.0
Correct answer: A
Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.
4. During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?
- A. Follow a systematic pattern from side-to-side moving down the client’s chest.
- B. Ask the client to breathe in deeply through their nose.
- C. Instruct the client to sit upright with their head slightly tilted backward.
- D. Place the diaphragm of the stethoscope on the client’s chest.
Correct answer: A
Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client’s chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client’s chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.
5. When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, what should be the next action by the nurse?
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contact with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct answer: A
Rationale: The correct action for the nurse in this situation is to discuss the feeling of reluctance with an objective peer or supervisor. By doing so, the nurse can address their emotions professionally and seek guidance on how to manage the situation effectively. This approach allows the nurse to receive support and potentially gain insights on how to navigate interactions with the manipulative client. Option B is incorrect because avoiding the client may not address the underlying issues causing the reluctance and can impact the quality of care provided. Option C is inappropriate as confronting the client directly about negative behaviors may escalate the situation and harm the therapeutic relationship. Option D is not the immediate action needed in this scenario; it is essential to address the nurse's feelings first before considering behavior modification plans.
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