HESI LPN
Fundamentals of Nursing HESI
1. What immediate action should a healthcare worker take after being stuck in the hand by an exposed needle?
- A. Look up the policy on needle sticks
- B. Contact employee health services
- C. Immediately wash the hands thoroughly with soap and water
- D. Notify the supervisor and risk management
Correct answer: C
Rationale: The correct immediate action for a healthcare worker who has been stuck by an exposed needle is to wash the hands thoroughly with soap and water to reduce the risk of infection. This helps to remove any potential pathogens introduced by the needle stick. Looking up the policy on needle sticks (Choice A) is important but not the immediate action required. Contacting employee health services (Choice B) and notifying the supervisor and risk management (Choice D) are crucial steps to take, but they should follow the initial step of washing the hands to mitigate the risk of infection.
2. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?
- A. Absent bowel sounds with distention
- B. Hyperactive bowel sounds
- C. Normal bowel sounds
- D. High-pitched bowel sounds
Correct answer: A
Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.
3. What should be done when caring for a client who died?
- A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
- B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
- C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
- D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.
Correct answer: A
Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.
4. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Assist the client with a partial bed bath
- B. Measure the client's BP after the nurse administers an antihypertensive medication
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct answer: A
Rationale: In this scenario, the nurse should assign the task of assisting the client with a partial bed bath to an assistive personnel (AP). APs are trained to provide basic care tasks like hygiene assistance. Options B, C, and D involve more complex tasks such as measuring BP, using a communication board for speech-impaired clients, and feeding, which require nursing judgment and skills beyond basic care. Therefore, these tasks should be performed by licensed nursing staff who can assess, communicate effectively, and address the specific medical and safety needs of the client.
5. How should the nurse transcribe the dosage of this medication on the client's medical record?
- A. 0.3 mg
- B. 0.3 mg
- C. 0.30 mg
- D. 3/10 mg
Correct answer: B
Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.
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