HESI LPN
Fundamentals of Nursing HESI
1. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
- A. When do you usually bathe, in the morning or evening?
- B. Do you prefer a bath or a shower?
- C. At what temperature do you prefer your bath water?
- D. Are you able to help with your hygiene care?
Correct answer: D
Rationale: The priority assessment question before beginning hygiene care for a new resident is determining if the resident is able to help with their hygiene care. This is essential to ensure the resident's safety during the procedure and prevent any potential injuries. Options A, B, and C, while relevant to providing personalized care, are not as critical as assessing the resident's ability to participate in their own hygiene care. Asking about the resident's ability to assist also promotes their independence and autonomy in self-care activities.
2. The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
- A. Leave the order for the oncoming staff to follow up
- B. Contact the charge nurse for an interpretation
- C. Ask the pharmacy for assistance in interpretation
- D. Call the provider for clarification
Correct answer: D
Rationale: The nurse should call the provider for clarification. In situations where there is difficulty reading an order, it is crucial to directly contact the healthcare provider to ensure the correct order is understood and followed. Leaving the order for the oncoming staff (Choice A) may lead to misunderstandings and errors. Contacting the charge nurse (Choice B) may cause delays as they may also need to contact the provider. Asking the pharmacy (Choice C) is not the most direct and immediate action in this scenario, as the provider is the one who can provide immediate clarification.
3. The healthcare provider is reviewing the plan of care for a client with a newly placed colostomy. Which outcome would indicate effective client teaching?
- A. Client demonstrates how to irrigate the colostomy.
- B. Client verbalizes understanding of dietary changes.
- C. Client performs ostomy care independently.
- D. Client expresses feelings about the impact of the colostomy.
Correct answer: C
Rationale: The correct answer is C because effective teaching is demonstrated when the client can independently perform ostomy care. This indicates that the client has understood and retained the information provided during teaching. Choices A, B, and D are incorrect because demonstrating how to irrigate the colostomy, verbalizing understanding of dietary changes, and expressing feelings about the impact of the colostomy are important aspects of care but do not directly reflect the client's ability to apply the taught information in a practical setting.
4. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?
- A. Administer pain medication 45 minutes before changing the client’s dressing.
- B. Change the dressing less frequently.
- C. Apply a topical anesthetic before removing the dressing.
- D. Use a non-adherent dressing to reduce pain.
Correct answer: A
Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.
5. A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct answer: C
Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.
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