HESI LPN
Fundamentals HESI
1. When administering an otic medication to an older adult client, which action should the nurse take to ensure that the medication reaches the inner ear?
- A. Press gently on the tragus of the client's ear
- B. Pack a small piece of cotton deep into the client's ear canal
- C. Move the client's auricle down and back toward their head
- D. Tilt the client's head backward for 5 minutes
Correct answer: A
Rationale: The correct action to ensure that otic medication reaches the inner ear is to press gently on the tragus. The tragus is a small cartilaginous projection in front of the ear canal. Pressing on it helps to straighten the ear canal, allowing the medication to reach the inner ear. Packing cotton or moving the auricle can obstruct the ear canal and prevent proper medication delivery. Tilting the client's head backward is not necessary and may not facilitate the medication reaching the inner ear as effectively as pressing on the tragus.
2. A healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?
- A. A client who had a laparoscopic appendectomy
- B. A client who had a mastectomy
- C. A client who had a left above-the-knee amputation
- D. A client who had a cardiac catheterization
Correct answer: C
Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.
3. To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should:
- A. Place the bed in a high horizontal position
- B. Use a low bed position
- C. Bend at the waist
- D. Keep the bed flat and at a comfortable working height
Correct answer: A
Rationale: When making an occupied bed for a client on bed rest, the nurse should place the bed in a high horizontal position to promote better body mechanics. This positioning helps reduce strain on the nurse's back and promotes proper alignment while working. Using a low bed position can lead to awkward bending and increased risk of musculoskeletal injuries. Bending at the waist is discouraged as it can strain the back. Keeping the bed flat and at a comfortable working height may not provide the optimal ergonomic setup needed to prevent injury.
4. A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching?
- A. “Our child wants to eat as much as we do, but we’re afraid it will lead to becoming overweight.â€
- B. “Our child skips lunch sometimes, but we figure it’s okay as long as we eat a healthy breakfast and dinner.â€
- C. “We limit fast-food restaurant meals to three times a week now.â€
- D. “We reward school achievements with a point system instead of pizza or ice cream.â€
Correct answer: D
Rationale: The correct answer is D. Rewarding school achievements with a point system rather than food items like pizza or ice cream is a healthier approach. This choice indicates an understanding of the teaching about nutrition and the importance of not using food as a reward. Choices A, B, and C do not demonstrate a clear understanding of the teaching as they focus on concerns about overeating, skipping meals, and limiting fast-food consumption but do not address the concept of avoiding food rewards for achievements.
5. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?
- A. Place a pad under the client’s head
- B. Hold the client’s limbs tightly to prevent injury
- C. Lift the client into bed with the help of other staff members
- D. Insert a bite block into the client’s mouth
Correct answer: A
Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.
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