HESI LPN
HESI Fundamentals Study Guide
1. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?
- A. Administer diphenhydramine (Benadryl)
- B. Discontinue the antibiotic infusion
- C. Apply a cool compress to the rash
- D. Notify the healthcare provider
Correct answer: B
Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.
2. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
- A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
- B. Assessing the color of the infant’s hands and feet
- C. Assessing the infant’s tongue
- D. Assessing the infant’s arms and legs
Correct answer: A
Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.
3. Two days after his last drink, a male alcoholic client becomes agitated and yells at his wife and children, 'Stay away from me!' His vital signs are elevated. What nursing diagnosis has the highest priority?
- A. High risk for social isolation.
- B. Altered parenting.
- C. Ineffective individual coping.
- D. High risk for injury.
Correct answer: D
Rationale: The correct answer is 'High risk for injury.' The client's agitation, elevated vital signs, and aggressive behavior pose a threat to himself and his family. Addressing the risk for injury is the priority to ensure the safety of all individuals involved. Choices A, B, and C are not the highest priority in this scenario. 'High risk for social isolation' does not address the immediate physical safety concern. 'Altered parenting' and 'Ineffective individual coping' are important but not as urgent as the risk for injury in this situation.
4. A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can use another nurse's password as long as I log off after using the computer
- B. I should encrypt personal health information when sending emails
- C. I can post the client's vital signs in the client's room
- D. I should discard personal health information documents in the trash before leaving the unit
Correct answer: B
Rationale: The correct answer is B because encrypting personal health information when sending emails is a crucial aspect of maintaining client confidentiality. This process ensures that sensitive information is protected during electronic communication. Choice A is incorrect as sharing passwords violates client confidentiality. Choice C is incorrect as posting client's vital signs breaches confidentiality. Choice D is incorrect as discarding personal health information in the trash can lead to unauthorized access.
5. At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Stay with the client and offer assistance with relaxation techniques
- B. Assess the client's pain level and administer pain medication if needed
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Encourage the client to engage in a quiet, non-stimulating activity until feeling sleepy
Correct answer: C
Rationale: At 0100 on the client's second postoperative night, the nurse should address the client's inability to sleep. Providing a prescribed PRN sedative-hypnotic is appropriate in this situation to help the client rest. Choice A is incorrect because leaving the room and closing the door does not directly address the client's sleep concern. Choice B is not the priority at this moment since the client's main issue is insomnia, not pain. Choice D, while encouraging a non-stimulating activity, does not provide immediate relief for the client's sleeplessness as a sedative-hypnotic would.