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 healthcare professional is collecting data to evaluate a middle adult's psychosocial development. The healthcare professional should expect middle adults to demonstrate which of the following developmental tasks? (Select ONE that does not apply.)
- A. Develop an acceptance of diminished strength and increased dependence on others.
- B. Spend time focusing on improving job performance.
- C. Welcome opportunities to be creative and productive.
- D. Commit to finding friendship and companionship.
Correct answer: A
Rationale: Middle adulthood is a stage where individuals typically focus on various developmental tasks. Option A is incorrect as middle adults do not necessarily develop an acceptance of diminished strength and increased dependence on others; they often strive to maintain independence. Option B is correct as middle adults are usually focused on improving job performance and advancing their careers. Option C is correct as middle adults tend to welcome opportunities to be creative and productive, engaging in new hobbies or projects. Option D is correct as middle adults often commit to finding friendship and companionship as they value social connections and support networks. Therefore, options B, C, and D are the expected developmental tasks for middle adults, making them the correct choices.
3. An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment?
- A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
- B. The nurse assigned to care for the client who was at lunch at the time of the fall.
- C. The nurse who transferred the client to the chair when the fall occurred.
- D. The charge nurse who completed rounds 30 minutes before the fall occurred.
Correct answer: C
Rationale: The nurse who transferred the client to the chair when the fall occurred is directly involved in the event that led to the injury. Improper transfer techniques or lack of appropriate precautions during the transfer could have contributed to the fall and subsequent fracture of the hip. This direct involvement makes this nurse the one at greatest risk for a malpractice judgment. Choices A, B, and D are not as directly linked to the event that caused the injury. While poor nursing notes could be a factor, it is the immediate action of transferring the client that has a more direct impact on the client's fall and subsequent injury.
4. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
- D. Before changing assignments, determine which staff members have fitted particulate filter masks
Correct answer: D
Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.
5. The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?
- A. Muscle weakness
- B. Joint pain
- C. Vision changes
- D. Skin rash
Correct answer: A
Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).
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