HESI LPN
HESI Fundamentals Test Bank
1. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The nurse wants to assess the client's gag reflex. Which action should the nurse include?
- A. Offer small sips of water through a straw
- B. Place tongue blade on back half of tongue
- C. Use a penlight to observe back of the oral cavity
- D. Auscultate breath sounds after the client swallows
Correct answer: B
Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.
2. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?
- A. “I will leave the IV catheter in place after the client completes the course of IV antibiotics.â€
- B. “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.â€
- C. “If my client needs to use the restroom, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.â€
- D. “I will replace any IV catheter when I suspect contamination during insertion.â€
Correct answer: D
Rationale: The correct answer is D: “I will replace any IV catheter when I suspect contamination during insertion.†This statement demonstrates an understanding of preventive strategies for IV infections. Suspecting and replacing any contaminated IV catheter during insertion is crucial to prevent infections and ensure patient safety. Choices A, B, and C are incorrect because leaving the IV catheter in place after completing antibiotics, reusing the same IV catheter, and disconnecting the IV infusion without proper precautions can increase the risk of infections. Therefore, option D is the best choice for preventing IV infections.
3. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?
- A. Teach deep breathing and coughing to the client.
- B. Assist the client to select food choices from the menu.
- C. Evaluate the client’s response to pain medication.
- D. Monitor the characteristics of the client's chest tube drainage.
Correct answer: B
Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.
4. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?
- A. Pull down and out at the back of the upper denture to remove.
- B. Brush the dentures with a toothbrush and denture cleaner.
- C. Rinse the dentures with hot water after cleaning them.
- D. Place the dentures in a clean, dry storage container after cleaning them.
Correct answer: B
Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.
5. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?
- A. Role overload
- B. Role conflict
- C. Role ambiguity
- D. Role strain
Correct answer: A
Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.
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