HESI LPN
HESI Fundamentals Exam Test Bank
1. 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.
2. During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?
- A. Counsel the client on medication adherence.
- B. Assess the client for medication reactions.
- C. Compile a list of the client's current medications.
- D. Evaluate the client's understanding of medications.
Correct answer: C
Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.
3. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?
- A. Encourage the client to relax and take deep breaths during the dressing change.
- B. Educate the client about the importance of pain management postoperatively.
- C. Assist the client to a comfortable position for the dressing change.
- D. Administer pain medication 45 minutes before changing the client's dressing.
Correct answer: D
Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.
4. A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?
- A. Input and output measurements for the shift
- B. Blood pressure readings from the previous day
- C. Bone scan scheduled for today
- D. Medication regimen from the medication administration record
Correct answer: D
Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.
5. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning?
- A. Case manager - responsible for overseeing a case load of clients but does not provide direct client care
- B. Client educator
- C. Client advocate
- D. Supervisor
Correct answer: D
Rationale: The correct answer is D: Supervisor. In this scenario, the nurse manager is acting as a supervisor to oversee and ensure the newly licensed nurse performs the straight catheterization correctly, following protocols, and maintaining client safety. A supervisor role involves monitoring and guiding staff in their duties to ensure quality care. Choices A, B, and C are incorrect. A case manager typically manages a case load of clients but does not provide direct care like in this situation. Client educator and client advocate roles do not directly relate to supervising or overseeing a procedure being performed by another nurse.
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