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 healthcare professional is planning care to improve self-feeding for a client with vision loss. Which of the following interventions should the healthcare professional include in the plan of care?
- A. Instruct the client on the sequence of foods to eat first
- B. Offer small-handle utensils for the client to use
- C. Thicken liquids served to the client
- D. Use a clock pattern to indicate food placement on the client's plate
Correct answer: D
Rationale: The correct answer is D. When a client has vision loss, using a clock pattern to describe food placement on the plate can facilitate independent eating. This method enables the client to locate different food items based on their positions, enhancing self-feeding abilities. Instructing the client on the sequence of foods to eat first (Choice A) may not address the visual impairment directly. Providing small-handle utensils (Choice B) can be helpful for clients with limited dexterity but may not specifically assist a client with vision loss. Thickening liquids (Choice C) is more relevant for clients with dysphagia, not vision loss.
3. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system.
- B. Use alcohol-based hand sanitizer when leaving the client's room.
- C. Clean contaminated surfaces in the client's room with a phenol solution.
- D. Have family members wear a gown and gloves when visiting.
Correct answer: D
Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.
4. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?
- A. Give the client information about immunization against meningitis.
- B. Tell the client to have a TB skin test every 2 years.
- C. Determine the client’s health risks.
- D. Teach the client about exercise recommendations.
Correct answer: C
Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.
5. A healthcare professional is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the healthcare professional question?
- A. Oral psyllium (Metamucil)
- B. Oral potassium supplement
- C. Parenteral half normal saline
- D. Parenteral albumin (Albuminar)
Correct answer: D
Rationale: The correct answer is D, Parenteral albumin (Albuminar). Parenteral albumin is not typically indicated for dehydration resulting from diarrhea. In this case, fluid replacement therapy with intravenous fluids such as parenteral half normal saline would be more appropriate. Oral psyllium and oral potassium supplement are not the primary interventions for managing dehydration due to watery diarrhea. Oral psyllium is a fiber supplement used for constipation rather than diarrhea. Oral potassium supplements may be necessary if potassium levels are low due to dehydration, but the priority is fluid replacement. Therefore, choices A and B are less relevant in this scenario.
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