HESI LPN
HESI Fundamentals Test Bank
1. A nurse is reviewing evidence-based practice principles about the administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate oxygen via nasal cannula at a flow rate no more than 6 L/min
- B. Administer oxygen at a higher flow rate for better saturation
- C. Use a high-flow nasal cannula for all clients
- D. Adjust oxygen flow based on client comfort
Correct answer: A
Rationale: The correct answer is A. Regulating oxygen flow at no more than 6 L/min via nasal cannula is a safe practice to prevent potential complications such as oxygen toxicity. Option B suggesting administering oxygen at a higher flow rate for better saturation is incorrect as it can lead to adverse effects. Option C is incorrect because using a high-flow nasal cannula for all clients is not necessary and should be based on individual client needs. Option D is incorrect as adjusting oxygen flow solely based on client comfort without considering the prescribed flow rate can compromise the effectiveness of oxygen therapy.
2. A client asks a nurse about the purpose of advance directives.
- A. Indicate a form of treatment a client is willing to accept.
- B. Specify the client's preferred hospital for treatment.
- C. Determine the client's daily medication schedule.
- D. Outline the client's financial status and insurance coverage.
Correct answer: A
Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.
3. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
- A. Contact the hospital’s spiritual services.
- B. Ask what is making the client cry.
- C. Ensure no visitors or staff enter the room for a short time period.
- D. Turn on the television for a distraction.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.
4. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
- A. The client is able to discuss the appropriate technique.
- B. The client is able to demonstrate the appropriate technique.
- C. The client states an understanding of the process.
- D. The client is able to write the steps on a piece of paper.
Correct answer: B
Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.
5. A client will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
- A. I'll make sure that, when my friend comes by, they smoke at least 6 feet away from my oxygen tank.
- B. I'll use a cotton blanket if I get chilly while I'm using my oxygen.
- C. I'll check the wires and cables on my oxygen equipment to make sure they are in good working order.
- D. I'll secure my oxygen tank in an upright position to prevent it from being knocked over.
Correct answer: C
Rationale: The correct answer is C. Ensuring the oxygen equipment's wires and cables are in good working order is crucial to prevent sparks in an oxygen-rich environment, which could lead to a fire. Choices A, B, and D are incorrect because smoking near an oxygen tank, using a cotton blanket near oxygen (as cotton is less likely to generate static electricity than wool), and laying the oxygen tank down on the floor pose significant safety risks and are not appropriate practices for managing oxygen therapy at home.
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