HESI LPN
HESI Fundamentals Exam
1. A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?
- A. It decreases the risk of injecting medication into a blood vessel.
- B. It delays medication absorption.
- C. It minimizes tissue irritation.
- D. It accelerates medication excretion.
Correct answer: C
Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.
2. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?
- A. Avoid taping electrical cords to the floor.
- B. Clean electrical equipment before disconnection.
- C. Cover exposed wires with tape before use.
- D. Disconnect electrical equipment by grasping the plug.
Correct answer: A
Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.
3. 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.
4. A client with a history of chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?
- A. I will keep my oxygen tank upright at all times.
- B. I will not use petroleum jelly to keep my nose from drying out.
- C. I will not smoke or allow others to smoke around me.
- D. I will call my doctor if I have difficulty breathing.
Correct answer: B
Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy as it can increase the risk of fire. Using petroleum jelly near oxygen can lead to a fire hazard. Choices A, C, and D are correct statements that indicate proper understanding of oxygen therapy safety measures. Choice A emphasizes the importance of keeping the oxygen tank upright to prevent leaks, choice C highlights the necessity of avoiding smoking to prevent exacerbation of COPD, and choice D encourages seeking medical help promptly in case of breathing difficulties.
5. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?
- A. The parents' name and telephone number
- B. The currency of the immunization and allergy history of the child
- C. The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
- D. The affected child's age and weight
Correct answer: D
Rationale: In the event of accidental poisoning, it is crucial to know the child's age and weight to determine the appropriate treatment. This information helps healthcare providers calculate the correct dosage of antidotes or medications needed based on the child's size and age. The child's age and weight play a significant role in managing accidental poisoning cases. Therefore, this information should be a priority for parents to communicate in such emergencies. Choices A, B, and C are not as critical as the child's age and weight when it comes to immediate treatment decisions for accidental poisoning.
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