HESI LPN
Fundamentals HESI
1. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Place the tablet under your tongue and let it dissolve completely.
- C. Swallow the tablet whole with a glass of water.
- D. Chew the tablet for faster relief.
Correct answer: B
Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to place the tablet under the tongue and let it dissolve completely. This route of administration allows for rapid absorption of the medication through the oral mucosa, providing quick relief for angina symptoms. Option A, taking the medication with food, is incorrect as nitroglycerin should be taken sublingually, not with food. Option C, swallowing the tablet whole with water, is incorrect as sublingual tablets should not be swallowed whole. Option D, chewing the tablet for faster relief, is also incorrect as chewing the tablet can lead to rapid absorption and potential adverse effects rather than a controlled release for angina relief.
2. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?
- A. Use gloves to inspect the hair.
- B. Apply a lindane-based shampoo immediately.
- C. Shave the patient's hair off.
- D. Ignore the movement and continue.
Correct answer: A
Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.
3. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?
- A. Check for catheter patency
- B. Assess the color of the urine
- C. Measure the urine output
- D. Ensure the catheter tubing is secure
Correct answer: C
Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.
4. Why should a nurse plan an evening snack for a child receiving Novolin N insulin?
- A. To encourage the child to adhere to the diet.
- B. To provide energy for immediate use.
- C. To help the child gain weight with extra calories.
- D. To counteract late insulin activity with nourishment.
Correct answer: D
Rationale: The correct answer is D. Novolin N insulin peaks in the evening, which can lead to hypoglycemia during the night. Providing an evening snack helps to counteract the late insulin activity and prevent hypoglycemia. Choice A is incorrect because the primary reason for the evening snack is not to encourage adherence to the diet. Choice B is incorrect as the snack is not primarily for immediate energy use. Choice C is incorrect as the goal of the snack is not to help the child gain weight but to manage blood sugar levels.
5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?
- A. Droplet precautions
- B. Contact precautions
- C. Airborne precautions
- D. Standard precautions
Correct answer: C
Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.