HESI LPN
HESI Fundamentals Study Guide
1. A healthcare professional is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the professional include?
- A. Urticaria
- B. Ptosis
- C. Nausea
- D. Hematuria
Correct answer: A
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. It presents as raised, red, itchy welts on the skin. Ptosis is drooping of the upper eyelid and is not typically associated with allergic reactions. Nausea is a gastrointestinal symptom that can occur with various conditions but is not specific to allergic reactions. Hematuria, which is the presence of blood in the urine, is not a typical manifestation of an allergic reaction.
2. A healthcare professional is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective
Correct answer: B
Rationale: The correct answer is B: Droplet. Droplet precautions are required for infections that spread via droplets larger than 5 microns in diameter, such as pharyngeal diphtheria. Contact precautions are used for diseases that spread by direct or indirect contact. Airborne precautions are for diseases that spread through small particles in the air. Protective precautions are not a standard precautionary measure for specific infections like pharyngeal diphtheria.
3. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?
- A. Risk for aspiration
- B. Impaired physical mobility
- C. Disturbed sensory perception
- D. Interrupted family processes
Correct answer: A
Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.
4. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.
5. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?
- A. Neck, shoulders, and chest
- B. Abdomen and groin/perineum
- C. Legs, feet, and web spaces
- D. Back of neck, back, and then buttocks
Correct answer: B
Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.
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