HESI LPN
HESI Fundamentals Study Guide
1. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:
- A. Establish an airway
- B. Call for assistance
- C. Check the client's pulse and blood pressure
- D. Perform CPR
Correct answer: A
Rationale: In a situation where a client is found unresponsive on the floor, the nurse's first priority is to establish an airway. This is crucial to ensure that the client can breathe adequately and receive oxygen. Without a patent airway, the client's oxygenation and ventilation may be compromised, leading to serious consequences. Calling for assistance is important, but establishing an airway takes precedence as it directly impacts the client's ability to breathe. Checking the client's pulse and blood pressure can be done after ensuring a clear airway. Performing CPR is not the immediate action needed unless the client's breathing and pulse are absent after the airway has been secured.
2. A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?
- A. Go over the surgical procedure with the patient before he or she is anesthetized
- B. Strictly adhere to asepsis during all intraoperative procedures
- C. Provide emotional support to the patient and their family
- D. Monitor the patient’s physical status
Correct answer: A
Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.
3. The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?
- A. These are normal signs of aging.
- B. These are early signs of dementia.
- C. These are purely psychological in origin.
- D. These are common manifestations with UTIs.
Correct answer: D
Rationale: The nurse should interpret confusion and agitation in an older adult patient with a UTI as common manifestations of the infection. In older patients, confusion is a primary symptom of a compromised state due to an acute urinary tract infection or fever. Choice A is incorrect as confusion and agitation are not normal signs of aging. Choice B is incorrect because these symptoms are more likely related to the UTI rather than early signs of dementia. Choice C is incorrect as confusion and agitation in this context are not purely psychological but are likely physiological responses to the UTI.
4. When caring for a patient diagnosed with diabetes mellitus and circulatory insufficiency, experiencing peripheral neuropathy and urinary incontinence, on which areas does the nurse focus care?
- A. Decreased pain sensation and increased risk of skin impairment
- B. Decreased caloric intake and accelerated wound healing
- C. High risk for skin infection and low saliva pH level
- D. High risk for impaired venous return and dementia
Correct answer: A
Rationale: The nurse should focus on decreased pain sensation and increased risk of skin impairment due to the patient's conditions. Peripheral neuropathy can lead to decreased pain sensation, making the patient more prone to injuries without realizing it. Additionally, the combination of circulatory insufficiency, peripheral neuropathy, and urinary incontinence can increase the risk of skin breakdown and impaired healing. Choices B, C, and D are incorrect because they do not address the specific issues related to the patient's diagnoses and symptoms.
5. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?
- A. Encourage the client to talk about the trauma.
- B. Help the client to focus on the present.
- C. Administer prescribed anti-anxiety medication.
- D. Leave the client alone to work through the flashback.
Correct answer: B
Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.