HESI LPN
HESI Fundamentals Exam Test Bank
1. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?
- A. Administer pain medication 45 minutes before changing the client’s dressing.
- B. Change the dressing less frequently.
- C. Apply a topical anesthetic before removing the dressing.
- D. Use a non-adherent dressing to reduce pain.
Correct answer: A
Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.
2. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
- A. The client reports severe pain
- B. The client asks for a demonstration
- C. The client inquires about potential complications
- D. The client agrees to the procedure
Correct answer: A
Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.
3. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
- A. Instruct the client to repeat the medication plan
- B. Encourage the client to take a PRN antianxiety drug
- C. Provide written instructions that are easy to follow
- D. Include a family member in the teaching session
Correct answer: D
Rationale: Including a family member in the teaching session is the most important action for the nurse to implement in this scenario. By involving a family member, the nurse can ensure that there is additional support and reinforcement of the medication plan. This can help the client and family better understand and adhere to the prescribed medications, reducing the client's anxiety. Instructing the client to repeat the medication plan (Choice A) may not address the client's anxiety effectively. Encouraging the client to take a PRN antianxiety drug (Choice B) should not be the first intervention without exploring other supportive measures. Providing written instructions (Choice C) alone may not offer the immediate support and reassurance needed for the anxious client.
4. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
5. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?
- A. Tie the restraint with a quick-release knot.
- B. Use a slipknot to secure the restraint.
- C. Ensure the restraint is tightly secured.
- D. Attach the restraint to the bed frame.
Correct answer: A
Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.
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