HESI LPN
HESI Fundamentals Test Bank
1. The healthcare professional is caring for a client with a chest tube. What is the most important action for the healthcare professional to take to ensure the chest tube is functioning properly?
- A. Milk the chest tube to ensure patency.
- B. Clamp the chest tube when moving the client.
- C. Ensure the water seal chamber is filled to the appropriate level.
- D. Secure the chest tube to the client's bed.
Correct answer: C
Rationale: Ensuring the water seal chamber is filled to the appropriate level is crucial to maintain the effectiveness of the chest tube drainage system. This step helps prevent air from entering the pleural space, ensuring proper lung re-expansion. 'Milking' the chest tube is not recommended as it can cause damage to the chest tube and surrounding tissues. Clamping the chest tube is not advisable as it can lead to tension pneumothorax. Securing the chest tube to the bed is important for stability but does not directly impact the functioning of the chest tube.
2. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
- A. Reassess the client to determine the reasons for inadequate pain relief.
- B. Wait to see whether the pain lessens during the next 24 hours.
- C. Change the plan of care to provide different pain relief interventions.
- D. Teach the client about the plan of care for managing pain.
Correct answer: A
Rationale: Reassessing the client is crucial to identify the reasons for inadequate pain relief. This action allows the nurse to gather more information, evaluate the current pain management interventions, and make necessary adjustments to the care plan. Waiting for the pain to lessen without taking action delays appropriate pain management. Changing the plan of care without reassessment may lead to ineffective interventions. Teaching the client about the plan of care should be based on a reassessment of the current pain relief status to ensure tailored and effective pain management strategies.
3. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
- A. Gently shake the container of medication prior to administration
- B. Transfer the medication to a medicine cup
- C. Place the client in a semi-Fowler’s position for medication administration
- D. Verify the dosage by measuring the liquid before administering it
Correct answer: A
Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.
4. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no-suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get an order from the healthcare provider's discharge order.
Correct answer: C
Rationale: The correct action for the nurse in this scenario is to engage the client in a discussion about their decision to leave and then prepare them for discharge. This approach allows the nurse to assess the client's current state, address concerns, and plan for a safe discharge. Option A is incorrect because it does not involve a therapeutic communication approach and may escalate the situation. Option B is incorrect as it places a condition on the client for release, which is not recommended in this situation. Option D is incorrect as it does not prioritize the client's autonomy and right to make decisions about their care.
5. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?
- A. Ask the client if he is okay.
- B. Call security from the room.
- C. Find out if there is anyone else in the room.
- D. Ask security to make sure the room is safe.
Correct answer: D
Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.
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