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. During a skin assessment, a client expresses concern about skin cancer due to a lesion on the anterior thigh. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
- A. An uneven shape
- B. A uniformly colored lesion
- C. A lesion that is small and flat
- D. A lesion that is less than 1 cm in diameter
Correct answer: A
Rationale: An uneven shape of a lesion is a common characteristic of malignant skin lesions. Asymmetric or irregularly shaped lesions are concerning for skin cancer and should be reported promptly for further evaluation and management. Choice B, a uniformly colored lesion, is more indicative of a benign lesion as malignant lesions often exhibit variations in color. Choice C, a lesion that is small and flat, does not necessarily indicate malignancy by itself. Choice D, a lesion that is less than 1 cm in diameter, is more suggestive of a benign lesion, as malignant lesions are typically larger in size.
3. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?
- A. Measure the client's vital signs.
- B. Assess the client's pain level.
- C. Verify the morphine order with another nurse.
- D. Check the client's last dose of morphine.
Correct answer: A
Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.
4. The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?
- A. Infuse normal saline at a keep-vein-open rate.
- B. Discontinue the IV and flush the port with heparin.
- C. Infuse 10% dextrose and water at 54 ml/hr.
- D. Obtain a stat blood glucose level and notify the healthcare provider.
Correct answer: C
Rationale: Infusing 10% dextrose and water at 54 ml/hr is the correct action to prevent hypoglycemia until the next TPN solution becomes available. This solution will help maintain the client's glucose levels. Infusing normal saline at a keep-vein-open rate (Choice A) is not appropriate for maintaining glucose levels and would not address the nutritional needs provided by TPN. Discontinuing the IV and flushing the port with heparin (Choice B) is unnecessary and not indicated in this situation as the client still needs fluid and nutrition. Obtaining a stat blood glucose level and notifying the healthcare provider (Choice D) can be done later but is not the immediate action required when the TPN solution has run out.
5. 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.
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