HESI LPN
HESI Fundamentals Test Bank
1. When planning home care for a 72-year-old client with osteomyelitis requiring a 6-week course of intravenous antibiotics, what is the most important action by the nurse?
- A. Investigating the client's insurance coverage for home IV antibiotic therapy
- B. Determining if there are adequate hand washing facilities in the home
- C. Assessing the client's ability to participate in self-care and/or the reliability of a caregiver
- D. Selecting the appropriate venous access device
Correct answer: C
Rationale: Assessing the client's ability to participate in self-care or evaluating the reliability of a caregiver is crucial in ensuring adherence to the treatment plan. This action helps determine if the client can manage the intravenous antibiotics at home independently or if assistance is needed. Investigating insurance coverage, ensuring hand washing facilities, and selecting the venous access device are important aspects of care but assessing the client's ability for self-care and caregiver reliability takes precedence to promote treatment success and safety.
2. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?
- A. Hydrocolloid
- B. Gauze
- C. Transparent film
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.
3. A nurse is reviewing evidence-based practice principles about the administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate oxygen via nasal cannula at a flow rate no more than 6 L/min
- B. Administer oxygen at a higher flow rate for better saturation
- C. Use a high-flow nasal cannula for all clients
- D. Adjust oxygen flow based on client comfort
Correct answer: A
Rationale: The correct answer is A. Regulating oxygen flow at no more than 6 L/min via nasal cannula is a safe practice to prevent potential complications such as oxygen toxicity. Option B suggesting administering oxygen at a higher flow rate for better saturation is incorrect as it can lead to adverse effects. Option C is incorrect because using a high-flow nasal cannula for all clients is not necessary and should be based on individual client needs. Option D is incorrect as adjusting oxygen flow solely based on client comfort without considering the prescribed flow rate can compromise the effectiveness of oxygen therapy.
4. While a client is receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?
- A. Monitor the client's blood glucose level every 4 hours.
- B. Change the TPN tubing every 72 hours.
- C. Weigh the client daily.
- D. Change the TPN bag every 24 hours.
Correct answer: D
Rationale: The correct action is to change the TPN bag every 24 hours to reduce the risk of infection. Changing the TPN tubing every 72 hours (Choice B) may increase the risk of contamination. Monitoring the client's blood glucose level every 4 hours (Choice A) is important but not specific to TPN administration. Weighing the client daily (Choice C) is essential for monitoring fluid status but is not directly related to TPN administration.
5. A healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)
- A. Develop an acceptance of diminished strength and increased dependence on others.
- B. Spend time focusing on improving job performance.
- C. Welcome opportunities to be creative and productive.
- D. Commit to finding friendship and companionship.
Correct answer: A
Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.
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