HESI LPN
HESI Fundamentals Test Bank
1. When performing cardiac chest compressions, what is a critical concept that the nurse must understand?
- A. Push hard and deep on the chest
- B. Compress the chest at a rapid rate
- C. Perform compressions with minimal interruptions
- D. Use a two-handed technique for compressions
Correct answer: A
Rationale: The correct answer is to 'Push hard and deep on the chest.' Effective chest compressions during CPR should be forceful and deep enough to adequately circulate blood to vital organs. This helps maintain perfusion and increases the likelihood of a successful outcome. Compressing the chest at a rapid rate (choice B) is important but not as critical as ensuring the compressions are hard and deep. Performing compressions with minimal interruptions (choice C) is also crucial to maintain blood flow. Using a two-handed technique for compressions (choice D) may be helpful but is not as critical as the depth and force of the compressions.
2. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Perform hand hygiene
- B. Identify the client using two identifiers
- C. Prepare the sterile field
- D. Don sterile gloves
Correct answer: A
Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.
3. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
4. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
- A. Establish goals that are measurable and realistic.
- B. Set goals that are a little beyond the capabilities of the patient.
- C. Use the nurse's own judgment and not be swayed by family desires.
- D. Explain that without taking alignment risks, there can be no progress.
Correct answer: A
Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.
5. The nurse is caring for an older adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?
- A. Encourage the patient to perform as many self-care activities as possible.
- B. Provide assistance with a bed bath to promote patient comfort.
- C. Coordinate with physical therapy for gait training.
- D. Instruct the patient to remain on bed rest to prevent fatigue.
Correct answer: A
Rationale: The correct answer is A: Encourage the patient to perform as many self-care activities as possible. For a patient who has had a stroke, promoting independence and engaging in self-care activities help maintain mobility and foster a sense of autonomy. Choices B, C, and D are incorrect because providing assistance with a bed bath, coordinating with physical therapy for gait training, or advising bed rest without indications may not be the best interventions for promoting optimal recovery and independence in a stroke patient.
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