HESI LPN
HESI Fundamentals 2023 Quizlet
1. A nurse is caring for a competent adult client who tells the nurse, 'I am leaving the hospital this morning whether the doctor discharges me or not.' The nurse believes that this is not in the client’s best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct answer: B
Rationale: The nurse is about to commit false imprisonment by unlawfully restricting the client's freedom of movement. In this scenario, the nurse's actions of preparing to administer sedative medication against the client's will in an effort to prevent them from leaving the hospital constitute false imprisonment. Assault (choice A) involves the threat of bodily harm, which is not present here. Negligence (choice C) refers to a breach in the duty of care, which is not the primary issue in this situation. Breach of confidentiality (choice D) involves disclosing confidential information without consent, which is unrelated to the scenario described.
2. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage
- B. Notify the pharmacy when wasting the medication
- C. Lock the remaining medication in the controlled substance cabinet
- D. Dispose of the vial with the remaining medication in a sharps container
Correct answer: A
Rationale: In medication wastage situations involving controlled substances, it is crucial to have a second nurse observe and verify the disposal process. This practice ensures accountability and prevents any mishandling or diversion of the medication. Choice B is incorrect because notifying the pharmacy is not the immediate action required in this scenario. Choice C is incorrect as locking the remaining medication in the controlled substance cabinet without proper witnessing does not ensure accountability. Choice D is incorrect as disposing of the vial with the remaining medication in a sharps container does not address the need for a witness to verify the wastage of the controlled substance.
3. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?
- A. Avoid taping electrical cords to the floor.
- B. Clean electrical equipment before disconnection.
- C. Cover exposed wires with tape before use.
- D. Disconnect electrical equipment by grasping the plug.
Correct answer: A
Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.
4. The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?
- A. Encourage the client to take deep breaths.
- B. Provide humidified oxygen via tracheostomy collar.
- C. Suction the tracheostomy tube as needed.
- D. Change the tracheostomy dressing daily.
Correct answer: C
Rationale: Suctioning the tracheostomy tube as needed is the most appropriate action in this scenario. When a client with a tracheostomy is unable to clear secretions by coughing, suctioning helps remove the excess secretions from the airway, ensuring proper breathing. Encouraging deep breaths (Choice A) may not effectively address the immediate need to clear secretions. Providing humidified oxygen (Choice B) can help with oxygenation but does not directly address the issue of clearing secretions. Changing the tracheostomy dressing daily (Choice D) is important for maintaining cleanliness but is not the priority when the client is unable to clear secretions.
5. A client had a mastectomy 6 months ago and expresses a decreased desire for sexual relations, stating “My body is so different now.†Which of the following responses should the nurse make?
- A. “Really, you look just fine to me. There’s no need to feel undesirable.â€
- B. “I’m interested in finding out more about how your body feels to you.â€
- C. “Consider an afternoon at a spa; a facial will make you feel more attractive.â€
- D. “It’s still too soon to expect to feel normal. Give it a little more time.â€
Correct answer: B
Rationale: In this situation, the appropriate response is to reflect on the client’s feelings and explore their experience. Choice A may unintentionally dismiss the client's concerns by not addressing their emotional needs. Choice C suggests a spa treatment as a solution without addressing the underlying emotional issues. Choice D implies that the client's feelings will resolve with time, which may not be helpful in addressing the client's current emotional state.
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