HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Inject the medication into the muscle.
- D. Pinch the skin before injecting.
Correct answer: B
Rationale: Enoxaparin is a medication that is administered subcutaneously, which means it should be injected into the fatty tissue layer beneath the skin. Administering enoxaparin at a 90-degree angle ensures proper absorption and reduces the risk of injecting the medication into muscle tissue, which could affect its effectiveness. Injecting the medication at a 45-degree angle may lead to improper absorption as it may not reach the subcutaneous tissue adequately. Injecting the medication into the muscle instead of subcutaneously can alter the absorption rate and therapeutic effects. Pinching the skin before injecting is not necessary for administering enoxaparin subcutaneously and may cause unnecessary discomfort to the client.
2. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. Allergies
- B. Scabies
- C. Regression
- D. Pinworms
Correct answer: D
Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.
3. A nurse is providing care to a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?
- A. Irrigate the catheter with sterile water daily.
- B. Empty the catheter bag every 8 hours.
- C. Clean the perineal area with antiseptic solution daily.
- D. Secure the catheter to the client's thigh.
Correct answer: D
Rationale: Securing the catheter to the client's thigh is the correct action to prevent CAUTIs. By securing the catheter, movement is minimized, reducing the risk of introducing bacteria into the urinary tract. Choice A is incorrect because routine irrigation of the catheter is not recommended as it can increase the risk of infection. Choice B is incorrect as emptying the catheter bag every 8 hours is important for proper drainage but does not directly prevent CAUTIs. Choice C is incorrect because cleaning the perineal area with antiseptic solution does not address the main source of CAUTIs related to catheter care.
4. The nurse is providing discharge teaching to a client who has been prescribed digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?
- A. I should take my pulse before taking the medication.
- B. I will take my medication at the same time every day.
- C. I should avoid taking antacids at the same time as this medication.
- D. I should eat foods high in potassium while taking this medication.
Correct answer: D
Rationale: The correct answer is D. Eating foods high in potassium can lead to hyperkalemia when taken with digoxin, indicating a need for further teaching. Choices A, B, and C are all correct statements that demonstrate understanding of digoxin therapy. Taking the pulse, maintaining a consistent dosing schedule, and avoiding antacids to prevent interactions with digoxin are all appropriate client responses.
5. A healthcare professional is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the healthcare professional take?
- A. Place the bladder of the cuff over the posterior aspect of the thigh
- B. Use a smaller cuff designed for lower extremities
- C. Place the cuff around the client's ankle
- D. Ensure the cuff is positioned above the knee
Correct answer: A
Rationale: When measuring blood pressure in the lower extremity, the bladder of the cuff should be placed over the posterior aspect of the thigh. This positioning ensures an accurate measurement. Placing the cuff around the ankle (Choice C) or above the knee (Choice D) would not provide an accurate blood pressure reading in the lower extremity. Using a smaller cuff designed for lower extremities (Choice B) is not appropriate as the standard cuff size should be used with the bladder placed over the posterior aspect of the thigh.
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