HESI LPN
Fundamentals of Nursing HESI
1. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?
- A. Assist the client with oral hygiene before taking the temperature.
- B. Inquire whether the client has smoked in the last 30 minutes.
- C. Connect the red tip probe to the thermometer unit.
- D. Position the probe tip against the client’s buccal mucosa.
Correct answer: B
Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.
2. A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Tuberculosis
Correct answer: D
Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.
3. When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?
- A. Frequency of previous vital sign measurements
- B. Number of family members who have visited
- C. Time of the client's last bath
- D. Effectiveness of the last dose of pain medication
Correct answer: D
Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.
4. A healthcare professional is caring for a group of clients. Which of the following measures should the professional take to prevent the spread of infection?
- A. Place a client with TB in a room with negative pressure airflow
- B. Use a disposable gown for contact precautions
- C. Place a client with MRSA in a private room
- D. Use a mask for clients with influenza
Correct answer: A
Rationale: Tuberculosis is an airborne infection, and placing a client with TB in a room with negative pressure airflow helps prevent the spread of the infection by containing the pathogens. This measure is crucial as it prevents the dissemination of TB droplet nuclei to other areas. Choice B, using a disposable gown for contact precautions, is important for preventing the transmission of infections spread by direct or indirect contact. Choice C, placing a client with MRSA in a private room, is essential to prevent the spread of MRSA through contact with others. Choice D, using a mask for clients with influenza, helps prevent the spread of influenza through respiratory droplets. However, negative pressure airflow is specifically required for airborne infections like TB, making it the most appropriate choice in this scenario.
5. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
- A. Monitoring evidence-based practice for clients with specific diagnoses.
- B. Ensuring that health care providers comply with regulations.
- C. Setting quality standards for accrediting health care facilities.
- D. Determining the safety of medications for administration to clients.
Correct answer: B
Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).
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