HESI LPN
Fundamentals of Nursing HESI
1. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?
- A. Writing a prescription for morphine sulfate as needed for pain
- B. Inserting a nasogastric (NG) tube to relieve gastric distention
- C. Showing a client how to use progressive muscle relaxation
- D. Performing a daily bath after the evening meal
Correct answer: C
Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.
2. What is the primary reason influencing most people's food choices?
- A. cost
- B. taste
- C. convenience
- D. nutritional value
Correct answer: B
Rationale: The primary reason most people choose the foods they eat is taste. While cost, convenience, and nutritional value also play a role in food choices, taste often takes precedence as people are more likely to select foods that they find appealing in flavor. Therefore, options A, C, and D are incorrect as taste is the chief factor influencing food choices.
3. What is a common sign of dehydration in infants?
- A. Decreased urination
- B. Dry mouth and lips
- C. Increased appetite
- D. Normal skin turgor
Correct answer: B
Rationale: Dry mouth and lips are common signs of dehydration in infants. When an infant is dehydrated, the body conserves water, resulting in less urine production and concentrated urine. This leads to decreased frequency of urination rather than frequent urination, making choice A incorrect. Choice C, increased appetite, is not typically associated with dehydration in infants but rather with normal growth and development. Normal skin turgor, as mentioned in choice D, is a sign of hydration and not dehydration, making it an incorrect choice. Therefore, the correct answer is B, dry mouth and lips, which indicate a need for fluid replacement.
4. A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?
- A. Enforce unit rules consistently with all clients.
- B. Ignore the manipulative behaviors to avoid confrontation.
- C. Provide the client with special privileges to avoid conflict.
- D. Confront the client directly about his behavior.
Correct answer: A
Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (Choice B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (Choice C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (Choice D) may escalate the situation and is less effective than consistent rule enforcement.
5. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
- A. 2 cups of soup
- B. 1 quart of water
- C. 8 oz of ice chips
- D. 6 oz of tea
Correct answer: C
Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.