HESI LPN
HESI Fundamentals Study Guide
1. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Autonomy
- C. Beneficence
- D. Justice
Correct answer: A
Rationale: The correct answer is A: Fidelity. Fidelity in nursing ethics involves keeping promises and being faithful to commitments, demonstrating reliability and trustworthiness. In this scenario, the nurse is exemplifying fidelity by returning promptly to the client as promised. Choice B, Autonomy, refers to respecting a patient's right to make their own decisions, not relevant in this situation. Choice C, Beneficence, involves the duty to act in the best interest of the patient, which is not the primary focus here. Choice D, Justice, pertains to fairness and equity in the distribution of healthcare resources, not applicable to the nurse's actions in this case.
2. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
- A. “This test will indicate if you are at risk for developing blood clots.”
- B. “This test will determine if your heart is performing properly.”
- C. “This test will provide information about the function of your liver.”
- D. “This test is used to check how your kidneys are working.”
Correct answer: C
Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.
3. A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?
- A. 4-5 times per hour
- B. 2-3 times per hour
- C. 6-7 times per hour
- D. 8-10 times per hour
Correct answer: A
Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.
4. A client is lying on the bathroom floor after a nurse responds to a call light. Which of the following actions should the nurse take first?
- A. Check the client for injuries
- B. Move hazardous objects away from the client
- C. Notify the provider
- D. Ask the client to describe how she felt prior to the fall
Correct answer: A
Rationale: The nurse's priority in this situation is to assess the client for injuries. Checking for injuries first is crucial to determine the extent of harm caused by the fall and to provide immediate care. Moving hazardous objects can wait until the client's safety is ensured. Notifying the provider and asking the client about how she felt prior to the fall are important but are secondary to assessing for injuries in this urgent scenario. It is essential to address immediate physical needs before investigating the cause of the fall or notifying other healthcare team members.
5. A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:
- A. Purulent
- B. Serous
- C. Sanguineous
- D. Serosanguineous
Correct answer: A
Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.
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