HESI LPN
Fundamentals of Nursing HESI
1. A client has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct answer: A
Rationale: Pharyngeal diphtheria is transmitted via droplets, primarily through respiratory secretions. Therefore, droplet precautions are necessary to prevent the spread of the infection. Droplet precautions involve wearing a surgical mask, goggles, and a gown when within three feet of the client. Contact precautions are used for diseases transmitted by direct or indirect contact; airborne precautions are for diseases transmitted through airborne particles; protective precautions are not a standard precaution type.
2. A client with asthma is prescribed a corticosteroid inhaler. Which instruction should the nurse provide to the client to prevent a common side effect of this medication?
- A. Use the inhaler only when experiencing asthma symptoms.
- B. Rinse the mouth with water after using the inhaler.
- C. Increase fluid intake while using the inhaler.
- D. Avoid eating or drinking for 30 minutes after using the inhaler.
Correct answer: B
Rationale: The correct instruction for the client using a corticosteroid inhaler to prevent a common side effect is to rinse the mouth with water after using the inhaler. Corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps reduce the risk of developing oral thrush. Choices A, C, and D are incorrect because using the inhaler only when experiencing symptoms, increasing fluid intake, or avoiding eating/drinking for 30 minutes after use are not directly related to preventing oral thrush, which is the common side effect associated with corticosteroid inhalers.
3. When conducting an admission assessment, the LPN should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?
- A. Complementary healing practices interfere with the efficacy of the medical model of treatment.
- B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
- C. Many complementary healing practices can be used in conjunction with conventional practices.
- D. Conventional medical practices will ultimately replace the use of complementary healing practices.
Correct answer: C
Rationale: When considering the use of complementary healing practices, it is important to acknowledge that many of these practices can be safely integrated with conventional treatments to provide holistic care. Choice A is incorrect because complementary healing practices can complement traditional medical approaches rather than interfere with their efficacy. Choice B is incorrect as interactions between conventional medications and folk remedies may vary, but not all interactions lead to adverse effects. Choice D is incorrect as conventional medical practices and complementary healing practices can coexist and each offer benefits in healthcare.
4. A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?
- A. Label the pump with a defective equipment sticker.
- B. Unplug the pump.
- C. Obtain a replacement pump.
- D. Notify the maintenance department to fix the pump.
Correct answer: B
Rationale: Unplugging the pump is the correct initial action in this situation to prevent any potential fire hazards. Sparks when plugging in the IV pump indicate an electrical issue that can lead to a fire. By immediately unplugging the pump, the healthcare professional ensures the safety of the client and prevents any further risks. Labeling the pump with a defective equipment sticker (Choice A) is not the priority as the immediate concern is safety. Obtaining a replacement pump (Choice C) can be considered after addressing the safety issue. Notifying the maintenance department (Choice D) is important but should follow the immediate action of unplugging the pump to mitigate the risk.
5. During an eye assessment, what action should the nurse take to assess a client's extraocular eye movements?
- A. Position the client 6.1 m (20 ft) away from the Snellen chart
- B. Instruct the client to follow a finger through the six cardinal positions of gaze
- C. Ask the client to cover their right eye during assessment of the left eye
- D. Hold a finger 46 cm (18 inches) away from the client's eye
Correct answer: B
Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action to assess extraocular eye movements effectively. This technique evaluates the function of the six extraocular muscles and cranial nerves III, IV, and VI. Positioning the client 6.1 m away from the Snellen chart is more relevant for visual acuity testing. Asking the client to cover their right eye during the assessment is not necessary for evaluating extraocular movements. Holding a finger at a specific distance in front of the client's eye is not an appropriate method for assessing extraocular eye movements.
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