HESI LPN
HESI Fundamentals Exam Test Bank
1. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct answer: C
Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.
2. When teaching a client and their family how to care for the client’s tracheostomy at home, which of the following should the nurse include?
- A. Use tracheostomy covers when outdoors
- B. Maintain a sterile technique when performing tracheostomy care
- C. Do not remove the outer cannula for routine cleaning
- D. Clean around the stoma with normal saline solution
Correct answer: A
Rationale: The correct answer is to use tracheostomy covers when outdoors. This practice helps protect the stoma from foreign particles and temperature changes, reducing the risk of infection. Maintaining a sterile technique when performing tracheostomy care (choice B) is important to prevent infections but is not specific to outdoor care. Removing the outer cannula for routine cleaning (choice C) is not recommended as it may cause trauma or dislodgment of the tracheostomy tube. Cleaning around the stoma with povidone-iodine (choice D) is not advisable as it can be irritating to the skin and may impair the healing process.
3. A PN is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile non-adherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct answer: B
Rationale: The correct answer is B: Moist sterile non-adherent dressing. A moist sterile non-adherent dressing is suitable for covering a neural tube defect and would not require further intervention. This type of dressing helps prevent the dressing from sticking to the wound, minimizing trauma during dressing changes. Choice A, Telfa dressing with antibiotic ointment, is not ideal for a neural tube defect as the ointment may not be necessary and can complicate wound care. Choice C, dry sterile dressing that is occlusive, is not recommended for a neural tube defect as it may not provide the necessary environment for proper wound healing. Choice D, sterile occlusive pressure dressing, is excessive for a neural tube defect and may cause unnecessary pressure on the wound site.
4. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?
- A. Place a client with TB in a room with negative pressure airflow
- B. Use a disposable gown for contact precautions
- C. Place a client with MRSA in a private room
- D. Use a mask for clients with influenza
Correct answer: A
Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.
5. When admitting a client, what information should the nurse record in the client’s record first?
- A. Assessment of the client
- B. Client’s medical history
- C. Plan of care
- D. Vital signs
Correct answer: A
Rationale: When admitting a client, the nurse's first step should be to assess the client. Assessment is crucial as it helps establish a baseline of the client's condition, identify any immediate concerns, and guide the development of an individualized plan of care. Recording the client's medical history, plan of care, or vital signs may follow the initial assessment but are secondary to the primary assessment process.
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