HESI LPN
HESI Fundamentals Test Bank
1. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?
- A. Dietitian consult
- B. Speech therapy referral
- C. Oral suction at the bedside
- D. Clear liquids
Correct answer: D
Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids or pureed foods. Therefore, the nurse should clarify the prescription for clear liquids to prevent potential harm to the client. Choices A, B, and C are appropriate interventions for a client with dysphagia following a stroke. A dietitian consult can help modify the client's diet for safe swallowing, speech therapy can assist in improving swallowing function, and oral suction at the bedside helps maintain airway patency and prevents aspiration.
2. The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?
- A. I should take the supplement with milk to increase absorption.
- B. I should expect my stools to turn black while taking this supplement.
- C. I should take the supplement with a full glass of water.
- D. I should take the supplement on an empty stomach.
Correct answer: A
Rationale: Taking an iron supplement with milk can decrease its absorption, indicating a need for further teaching.
3. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?
- A. Lock the wheels on the bed and gurney
- B. Adjust the bed height
- C. Use a slide sheet
- D. Ask for assistance from another nurse
Correct answer: A
Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.
4. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:
- A. Check the client’s identification bracelet
- B. Inform the client about the procedure
- C. Prepare the client for transport
- D. Verify the x-ray order
Correct answer: A
Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.
5. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?
- A. Corn pads are an adequate treatment and should be continued.
- B. The patient should avoid soaking the feet before using a pumice stone.
- C. The current self-treatment is likely impeding circulation to the toes.
- D. Tighter shoes would help compress the corns and make them smaller.
Correct answer: C
Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.
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