HESI LPN
Fundamentals of Nursing HESI
1. A client with diabetes mellitus and a new prescription for insulin is being discharged. Which of the following actions should the nurse plan to complete first?
- A. Provide the client with printed information on insulin self-administration.
- B. Obtain printed information on insulin self-administration.
- C. Make a copy of the medication reconciliation form for the client.
- D. Determine whether the client can afford the insulin administration supplies.
Correct answer: B
Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.
2. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
- A. Swelling and redness in the affected leg
- B. Pain in the affected leg
- C. Warmth and tenderness in the affected leg
- D. A positive Homans' sign
Correct answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
3. A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Nonmaleficence
Correct answer: D
Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.
4. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?
- A. Our child had chickenpox 6 months ago.
- B. Strep throat went through all the children at the day care last month.
- C. Both ears were infected over 3 months ago.
- D. Last week both feet had a fungal skin infection.
Correct answer: B
Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.
5. A client has a new prescription for a metered-dose inhaler. Which of the following instructions should the nurse include?
- A. Inhale quickly and deeply while pressing down on the inhaler.
- B. Hold your breath for 10 seconds after inhaling the medication.
- C. Exhale immediately after inhaling the medication.
- D. Shake the inhaler before each use.
Correct answer: B
Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.
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