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. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
3. A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging?
- A. Slower light touch sensation
- B. Some vision and hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
Correct answer: B
Rationale: As individuals age, it is common to experience changes in vision and hearing, leading to some decline in these senses. Slower light touch sensation and slower fine finger movement are also typical findings associated with aging. However, some short-term memory decline is more closely related to cognitive aging rather than typical age-related changes in the neurologic system. Therefore, the correct answer is the decline in vision and hearing. Decreased risk of depression is not a typical finding in aging; in fact, the risk of depression may increase as individuals age.
4. A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?
- A. What is your daily calorie consumption?
- B. What vitamin and mineral supplements do you take?
- C. Do you feel that you are overweight?
- D. Will a clear liquid diet be okay after surgery?
Correct answer: B
Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.
5. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?
- A. Hand rolls
- B. A foot cradle
- C. A trapeze bar
- D. A trochanter roll
Correct answer: B
Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.
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