HESI LPN
HESI Fundamentals Study Guide
1. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?
- A. Allowing the client to function independently will strengthen muscles and promote healing.
- B. The client needs privacy at times for self-reflection and organizing life.
- C. The client’s sense of loss can be lessened through retaining control of some areas of life.
- D. Performing ADLs is a requirement prior to discharge from an acute care facility.
Correct answer: C
Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.
2. Which of the following techniques represents the most appropriate method of opening the airway of an infant with no suspected neck injury?
- A. lift up the chin and hyperextend the neck
- B. tilt the head back without hyperextending the neck
- C. gently lift the chin while maintaining slight flexion of the neck
- D. perform the technique as you would for an older child or adult
Correct answer: B
Rationale: The correct technique for opening the airway of an infant with no suspected neck injury is to tilt the head back without hyperextending the neck. This method helps to keep the airway open without risking injury to the infant's delicate neck structures. Choice A, lifting up the chin and hyperextending the neck, can potentially harm the infant's neck. Choice C, gently lifting the chin while maintaining slight flexion of the neck, is not as effective as tilting the head back. Choice D is incorrect as infants require a different approach compared to older children or adults due to their anatomical differences.
3. When caring for a patient with a fresh tracheostomy, what is the nurse’s first priority?
- A. Providing humidified oxygen
- B. Ensuring the tracheostomy ties are secure
- C. Suctioning the tracheostomy tube as needed
- D. Monitoring for signs of infection
Correct answer: B
Rationale: The correct answer is B: Ensuring the tracheostomy ties are secure. This is the nurse's first priority because it is critical to prevent accidental decannulation, which could compromise the patient’s airway. Providing humidified oxygen, suctioning the tracheostomy tube, and monitoring for signs of infection are important aspects of care but ensuring the tracheostomy ties' security takes precedence to maintain the patient's airway.
4. What is usually the first contact between community members and other levels of health facilities called?
- A. Secondary level health care
- B. Primary health care
- C. Tertiary level care
- D. Intermediate level care
Correct answer: B
Rationale: The correct answer is B: Primary health care. Primary health care is the initial point of contact between community members and the healthcare system. This level of care focuses on preventive and primary treatment services. Choices A, C, and D are incorrect because secondary, tertiary, and intermediate care levels are more specialized and are usually accessed after primary care, depending on the complexity of the health issue.
5. A client who received a renal transplant three months ago is readmitted to the acute care unit with signs of graft rejection. While taking the client's history, the nurse determines the client has been self-administering St. John's wort, an herbal preparation, on the advice of a friend. What information is most significant about this finding?
- A. Wort can decrease plasma concentration of Cyclospora
- B. Wort can decrease plasma concentration of Tacrolimus
- C. Wort can decrease plasma concentration of Cyclosporine
- D. Wort can decrease plasma concentration of Mycophenolate
Correct answer: C
Rationale: The most significant information about the client self-administering St. John's wort, an herbal preparation, is that it can decrease the plasma concentration of Cyclosporine. St. John's wort is known to reduce the efficacy of Cyclosporine, which is a common immunosuppressant drug used to prevent transplant rejection. Choices A, B, and D are incorrect because St. John's wort does not affect the plasma concentration of Cyclospora, Tacrolimus, or Mycophenolate.