HESI LPN
HESI Fundamentals Exam
1. A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?
- A. Apply an ice pack to the client's back for 1 hour.
- B. Remove distractions from the client’s room.
- C. Instruct the client to take deep rhythmic breaths.
- D. Encourage the client to apply a heating pad for 2 hours at a time.
Correct answer: C
Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.
2. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
- A. Gently shake the container of medication prior to administration
- B. Transfer the medication to a medicine cup
- C. Place the client in a semi-Fowler’s position for medication administration
- D. Verify the dosage by measuring the liquid before administering it
Correct answer: A
Rationale: The correct action for the nurse to take is to gently shake the container of liquid medication before administration. Shaking the container ensures proper mixing of the medication, which is important to maintain uniformity of the dose. Transferring the medication to a medicine cup (choice B) may not be necessary for a small volume like 0.5 mL. Placing the client in a semi-Fowler's position (choice C) is not directly related to administering liquid medication orally. Verifying the dosage by measuring the liquid (choice D) is important but does not address the specific action needed to prepare the medication for administration.
3. The healthcare provider is observing the way a patient walks. Which aspect is the healthcare provider assessing?
- A. Activity tolerance
- B. Body alignment
- C. Range of motion
- D. Gait
Correct answer: D
Rationale: When assessing the way a patient walks, the healthcare provider is evaluating the gait, which refers to a particular manner or style of walking. Body alignment pertains to the positioning of body parts in relation to one another, range of motion refers to the extent of movement of a joint, and activity tolerance relates to the ability to endure physical activities. In this scenario, observing the patient's walking pattern specifically focuses on gait assessment.
4. When a client files a lawsuit against an LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:
- A. Evidence
- B. Tort discovery
- C. Proximate cause
- D. Common cause
Correct answer: C
Rationale: The correct answer is C, 'Proximate cause.' Proximate cause establishes the link between the harm suffered and the negligent actions performed by the nurse. In a malpractice lawsuit, proving proximate cause is essential to demonstrate that the nurse's actions directly led to the harm experienced by the client. Choice A, 'Evidence,' is incorrect as evidence is the information presented to support or refute a claim, not specifically the link between harm and negligence. Choice B, 'Tort discovery,' is incorrect as it does not specifically refer to establishing the link between harm and negligence. Choice D, 'Common cause,' is incorrect as it does not capture the legal concept of proximate cause in establishing liability in malpractice cases.
5. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?
- A. Complete a fall-risk assessment.
- B. Educate the client and family about fall risks.
- C. Eliminate safety hazards from the client’s environment.
- D. Ensure the client uses assistive aids in their possession.
Correct answer: C
Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.
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