HESI LPN
HESI Fundamentals Exam
1. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?
- A. Teaching the client about the purpose of the medication
- B. Giving the medication at the administration time the provider prescribed
- C. Identifying the client’s medication allergies
- D. Documenting the client’s anxiety level
Correct answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.
2. A nurse is caring for a group of clients. How should the nurse prevent the spread of infection?
- A. Place a client with TB in a negative pressure room.
- B. Use standard precautions only.
- C. Place a client with TB in a private room.
- D. Use barrier precautions only.
Correct answer: A
Rationale: The correct answer is to place a client with TB in a negative pressure room. Tuberculosis (TB) is an airborne infectious disease, and placing the client in a negative pressure room helps prevent the spread of the infection by containing and filtering the air within the room. Standard precautions (Choice B) are important for preventing the spread of infection in general, but specific precautions are needed for airborne diseases like TB. Placing the client in a private room (Choice C) may not provide adequate ventilation and containment of airborne pathogens. Using barrier precautions (Choice D) alone is not sufficient for preventing the airborne transmission of TB.
3. What immediate action should a healthcare worker take after being stuck in the hand by an exposed needle?
- A. Look up the policy on needle sticks
- B. Contact employee health services
- C. Immediately wash the hands thoroughly with soap and water
- D. Notify the supervisor and risk management
Correct answer: C
Rationale: The correct immediate action for a healthcare worker who has been stuck by an exposed needle is to wash the hands thoroughly with soap and water to reduce the risk of infection. This helps to remove any potential pathogens introduced by the needle stick. Looking up the policy on needle sticks (Choice A) is important but not the immediate action required. Contacting employee health services (Choice B) and notifying the supervisor and risk management (Choice D) are crucial steps to take, but they should follow the initial step of washing the hands to mitigate the risk of infection.
4. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?
- A. Perform a bladder scan to assess for urinary retention.
- B. Encourage the client to drink fluids.
- C. Insert a straight catheter to drain the bladder.
- D. Administer a diuretic as prescribed.
Correct answer: A
Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.
5. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Abdomen
- D. Inner forearm
Correct answer: D
Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.
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