HESI LPN
Fundamentals HESI
1. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.
- A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
- B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
- C.
- D.
Correct answer: B
Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.
2. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client’s BP.
Correct answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
3. A nurse is caring for a competent adult client who tells the nurse, 'I am leaving the hospital this morning whether the doctor discharges me or not.' The nurse believes that this is not in the client’s best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct answer: B
Rationale: The nurse is about to commit false imprisonment by unlawfully restricting the client's freedom of movement. In this scenario, the nurse's actions of preparing to administer sedative medication against the client's will in an effort to prevent them from leaving the hospital constitute false imprisonment. Assault (choice A) involves the threat of bodily harm, which is not present here. Negligence (choice C) refers to a breach in the duty of care, which is not the primary issue in this situation. Breach of confidentiality (choice D) involves disclosing confidential information without consent, which is unrelated to the scenario described.
4. When assessing bowel sounds, what action should a healthcare professional take?
- A. Listen to the bowel sounds before performing abdominal palpation
- B. Auscultate for 2 minutes to determine if bowel sounds are present
- C. Place the diaphragm of the stethoscope over each quadrant
- D. Ask the client to cough while auscultating
Correct answer: C
Rationale: When assessing bowel sounds, it is crucial to listen before performing any palpation as palpation can alter bowel sounds. The correct technique involves placing the diaphragm of the stethoscope over each quadrant of the abdomen to listen for bowel sounds. Auscultating for at least 5 minutes is recommended to accurately determine the presence or absence of bowel sounds. Asking the client to cough is not necessary for assessing bowel sounds and may not provide relevant information. Therefore, option C is the correct choice as it follows the appropriate procedure for assessing bowel sounds.
5. The nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Avoid abbreviating medication names to prevent errors.
- C. Use generic names only for medications.
- D. Document the dosage, route of administration, and complete medication name.
Correct answer: A
Rationale: The correct answer is A: 'Use the complete name of the medication magnesium sulfate.' When documenting medications, it is crucial to use the complete name to avoid confusion and errors. Abbreviating medication names (choice B) can lead to misinterpretation and errors in medication administration. Using generic names only for medications (choice C) may not provide enough specificity, leading to potential medication errors. While documenting the dosage and route of administration is important, it is also vital to include the complete medication name (choice D) for accurate record-keeping and to ensure clarity in medication administration.
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