HESI LPN
Fundamentals of Nursing HESI
1. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
- A. Obtaining cotton balls for the tracheostomy care
- B. Using a sterile water bottle
- C. Checking the suction equipment
- D. Wearing a sterile gown
Correct answer: A
Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.
2. A client with a diagnosis of hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide?
- A. Take the medication at bedtime.
- B. Take the medication with food.
- C. Report any symptoms of hyperthyroidism.
- D. Discontinue the medication if you feel well.
Correct answer: C
Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to report any symptoms of hyperthyroidism. Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate overtreatment or excessive dosing of levothyroxine. Prompt reporting of these symptoms is crucial to prevent serious complications. Choices A and B are not the most critical information related to levothyroxine administration. Instructing the client to take the medication at bedtime or with food can be important for adherence but is not as crucial as monitoring for signs of hyperthyroidism. Choice D is incorrect as discontinuing the medication if feeling well can lead to a relapse of hypothyroidism symptoms.
3. Based on the interpretation of this strip, what action should be implemented first?
- A. Call a code.
- B. Start CPR.
- C. Administer IV fluids.
- D. Apply oxygen.
Correct answer: A
Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.
4. A client with a history of atrial fibrillation is prescribed digoxin. The nurse should monitor for which sign of digoxin toxicity?
- A. Bradycardia
- B. Tachycardia
- C. Nausea
- D. Vomiting
Correct answer: A
Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat atrial fibrillation, can lead to toxicity manifesting as various cardiac dysrhythmias, with bradycardia being a notable indicator. Monitoring for bradycardia is crucial as it can indicate the need for dosage adjustment or discontinuation of digoxin to prevent adverse effects. Tachycardia, nausea, and vomiting are not typically associated with digoxin toxicity, making them incorrect choices for monitoring in a client receiving this medication.
5. A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?
- A. Ask the client to sit down and relax.
- B. Administer a PRN dose of antipsychotic medication.
- C. Encourage the client to talk about what is making him anxious.
- D. Monitor the client for adverse reactions to the medication.
Correct answer: B
Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.