HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?
- A. Ask the client to state their full name.
- B. Ask the client for their date of birth.
- C. Compare the client's wristband with the medication administration record.
- D. Ask the client for their room number.
Correct answer: C
Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.
2. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?
- A. Fluid volume deficit
- B. Altered nutrition: less than body requirements
- C. Anxiety related to new situational crisis
- D. Activity intolerance related to fatigue
Correct answer: A
Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.
3. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?
- A. Consult the medication reference book available on the unit.
- B. Administer the medication as ordered.
- C. Ask a colleague for information about the medication.
- D. Contact the provider to clarify the medication.
Correct answer: A
Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.
4. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer?
- A. 1 ml.
- B. 1.5 ml.
- C. 1.75 ml.
- D. 2 ml.
Correct answer: B
Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.
5. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the LPN/LVN take to maintain patency of the tube?
- A. Flush the tube with 30 ml of water before and after medication administration.
- B. Secure the tube to the client's gown.
- C. Check the placement of the tube by auscultation.
- D. Irrigate the tube with normal saline every shift.
Correct answer: A
Rationale: The correct action to maintain patency of a nasogastric (NG) tube is to flush the tube with water before and after medication administration. Flushing helps prevent clogging and ensures that the tube remains clear for proper functioning. Securing the tube to the client's gown (Choice B) is important for stability but does not directly address tube patency. Checking the placement of the tube by auscultation (Choice C) is crucial for verifying correct placement but does not specifically relate to maintaining tube patency. Irrigating the tube with normal saline every shift (Choice D) is not a routine practice for maintaining tube patency and can lead to electrolyte imbalances.
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