HESI LPN
Practice HESI Fundamentals Exam
1. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?
- A. Wearing gloves during the procedure
- B. Using a sterile solution
- C. Irrigating from the inner to the outer canthus
- D. Positioning the client's head properly
Correct answer: A
Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.
2. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- A. Wear cotton clothing to avoid static electricity.
- B. Avoid using any electrical appliances.
- C. Keep the oxygen tank away from heat sources.
- D. Use only a specific type of nasal cannula.
Correct answer: A
Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.
3. When performing nasotracheal suctioning on a client with a respiratory infection, what technique should be used?
- A. Apply intermittent suction when withdrawing the catheter.
- B. Apply continuous suction during insertion of the catheter.
- C. Apply suction only during insertion of the catheter.
- D. Insert the catheter while the client is exhaling.
Correct answer: A
Rationale: The correct technique for nasotracheal suctioning is to apply intermittent suction when withdrawing the catheter. This method helps prevent damage to the mucosa and is the recommended approach. Continuous suction during insertion (choice B) can cause trauma to the airway lining. Applying suction only during insertion (choice C) is not sufficient for effective removal of secretions. Inserting the catheter while the client is exhaling (choice D) does not follow the standard procedure for nasotracheal suctioning.
4. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
- A. Irrigate the affected area with running water.
- B. Wash the affected area with antibacterial soap.
- C. Brush the chemical off the skin and clothing.
- D. Leave the clothing in place until emergency personnel arrive.
Correct answer: C
Rationale: The correct intervention for an employee exposed to an unknown dry chemical is to brush off the chemical from the skin and clothing. This helps prevent further skin contact before irrigation can be done. Irrigating the affected area with running water is crucial after brushing off the chemical to minimize the exposure. Washing the affected area with antibacterial soap is not appropriate for chemical burns, as soap can react with certain chemicals and worsen the situation. Leaving the clothing in place until emergency personnel arrive may allow the chemical to continue to harm the skin and should be avoided.
5. A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?
- A. We will determine who the durable power of attorney for health care form has designated.
- B. We will apply oxygen through a tube in your nose.
- C. We will ask if you have changed your mind.
- D. We will insert a breathing tube while we evaluate your condition.
Correct answer: B
Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.
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