HESI LPN
HESI Fundamentals 2023 Quizlet
1. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
- A. Contact the hospital’s spiritual services.
- B. Ask what is making the client cry.
- C. Ensure no visitors or staff enter the room for a short time period.
- D. Turn on the television for a distraction.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.
2. Under the provisions of the Americans with Disabilities Act, what are nurse managers required to do?
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct answer: B
Rationale: The correct answer is B: 'Provide reasonable accommodations for disabled individuals.' The Americans with Disabilities Act (ADA) mandates nurse managers to offer reasonable accommodations for disabled individuals to ensure equal opportunities in the workplace. Choice A is incorrect because although maintaining a hazard-free environment is essential, the focus of the ADA is on accommodations for disabled individuals. Choice C is incorrect as it overly generalizes the accommodations without specifying the need for them to be 'reasonable.' Choice D is incorrect because the ADA does not specify a requirement to consider both mental and physical disabilities; instead, it emphasizes providing reasonable accommodations regardless of the disability type.
3. A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin in the same body area each time.
- B. Store the insulin according to the manufacturer's instructions.
- C. Rotate injection sites within the same body area.
- D. Inject the insulin at a 45-degree angle.
Correct answer: C
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.
4. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic
- B. Obtain current client data to compare with expected outcomes
- C. Modify the nursing interventions to achieve the client's goals
- D. Review related professional standards of care
Correct answer: B
Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.
5. A healthcare provider is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the provider identify as an adverse effect of opioids?
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
Correct answer: D
Rationale: The correct answer is D: Orthostatic hypotension. Opioids can cause orthostatic hypotension, leading to a sudden drop in blood pressure when changing positions. This effect is due to the vasodilatory properties of opioids, which can result in decreased blood flow to the brain upon standing up. Choices A, B, and C are incorrect. Urinary incontinence and diarrhea are not typical adverse effects of opioids. Bradypnea, or slow breathing, is a potential side effect of opioid overdose or respiratory depression, but it is not a common adverse effect following normal opioid administration.
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