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. While a client is receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?
- A. Monitor the client's blood glucose level every 4 hours.
- B. Change the TPN tubing every 72 hours.
- C. Weigh the client daily.
- D. Change the TPN bag every 24 hours.
Correct answer: D
Rationale: The correct action is to change the TPN bag every 24 hours to reduce the risk of infection. Changing the TPN tubing every 72 hours (Choice B) may increase the risk of contamination. Monitoring the client's blood glucose level every 4 hours (Choice A) is important but not specific to TPN administration. Weighing the client daily (Choice C) is essential for monitoring fluid status but is not directly related to TPN administration.
3. A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. People in middle adulthood often find satisfaction in nurturing and guiding young people.
- B. It's normal to feel this way; it will pass.
- C. You should focus on finding new activities to fill your time.
- D. Your children will always need you in some way.
Correct answer: A
Rationale: The correct response is A. Middle adulthood is a stage where individuals often experience generativity, finding fulfillment in guiding and nurturing others. By acknowledging this aspect, the nurse can help the client explore opportunities to engage in activities that provide a sense of purpose and satisfaction. Choice A validates the client's feelings and offers a constructive way to address them. Choices B, C, and D do not address the client's emotional need for purpose and may not encourage the client to seek meaningful ways to address their feelings of uselessness.
4. A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?
- A. Ignore the client’s discomfort
- B. Reassure the client without addressing concerns
- C. Is there something about this procedure that concerns you?
- D. Proceed with the procedure
Correct answer: C
Rationale: The appropriate nursing response in this situation is to ask the client if there are any concerns about the procedure. By doing so, the nurse acknowledges the client's distress and opens up a dialogue to address any anxieties or misconceptions. Option A is incorrect as ignoring the client’s discomfort can lead to increased anxiety and potential harm. Option B is not ideal as reassuring the client without addressing specific concerns may not alleviate the client's distress. Option D is incorrect because proceeding with the procedure without addressing the client's unspoken concerns can further escalate the client's distress.
5. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
- A. Irrigate the affected area with running water.
- B. Wash the affected area with antibacterial soap.
- C. Brush the chemical off the skin and clothing.
- D. Leave the clothing in place until emergency personnel arrive.
Correct answer: C
Rationale: The correct intervention for an employee exposed to an unknown dry chemical is to brush off the chemical from the skin and clothing. This helps prevent further skin contact before irrigation can be done. Irrigating the affected area with running water is crucial after brushing off the chemical to minimize the exposure. Washing the affected area with antibacterial soap is not appropriate for chemical burns, as soap can react with certain chemicals and worsen the situation. Leaving the clothing in place until emergency personnel arrive may allow the chemical to continue to harm the skin and should be avoided.
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