HESI LPN
HESI Fundamentals Study Guide
1. A client reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?
- A. Provide a late supper
- B. Offer a wet washcloth for the client to wash their face
- C. Perform range of motion exercises
- D. Prepare a hot cocoa or tea for the client
Correct answer: B
Rationale: Offering a wet washcloth for the client to wash their face is a soothing and calming activity that can help the client relax before bedtime, promoting better sleep. Providing a late supper can lead to indigestion and disrupt sleep. Performing range of motion exercises may increase alertness rather than promoting relaxation. Preparing a hot cocoa or tea containing caffeine close to bedtime can interfere with falling asleep.
2. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?
- A. 'I can see that this is upsetting you.'
- B. 'It is necessary for your treatment.'
- C. 'It will be over quickly, and you will feel better.'
- D. 'Let me explain again why this procedure is important.'
Correct answer: A
Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.
3. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?
- A. Encourage the client to relax and take deep breaths during the dressing change.
- B. Educate the client about the importance of pain management postoperatively.
- C. Assist the client to a comfortable position for the dressing change.
- D. Administer pain medication 45 minutes before changing the client's dressing.
Correct answer: D
Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.
4. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
- A. The nurse opens the sterile field on a wet surface.
- B. The nurse turns away from the sterile field.
- C. The nurse uses a non-sterile glove to touch the sterile field.
- D. The nurse touches the edge of the sterile drape with her hand.
Correct answer: A
Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.
5. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?
- A. Role overload
- B. Role conflict
- C. Role ambiguity
- D. Role strain
Correct answer: A
Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.
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