HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client is being taught how to care for their tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
- A. Use tracheostomy covers when outdoors.
- B. Clean the tracheostomy site with hydrogen peroxide daily.
- C. Change the tracheostomy tube weekly.
- D. Apply ointment around the tracheostomy site.
Correct answer: A
Rationale: The correct instruction is to use tracheostomy covers when outdoors. Tracheostomy covers serve to protect the airway from environmental contaminants, reducing the risk of infection. Choice B is incorrect because hydrogen peroxide can be irritating to the skin and is not recommended for cleaning the tracheostomy site. Choice C is incorrect as tracheostomy tubes should not be routinely changed weekly unless there is a specific medical indication. Changing it without a need can introduce infection or damage the stoma. Choice D is incorrect as applying ointment around the tracheostomy site can lead to occlusion of the stoma and interfere with breathing.
2. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?
- A. Establish rapport in each phase of the nurse-client relationship.
- B. Determine the client's ability to communicate effectively.
- C. Reflect on previous psychiatric interviews the nurse has performed.
- D. Ensure data is collected and recorded in a systematic sequence.
Correct answer: A
Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.
3. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
4. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct answer: A
Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.
5. The nurse caring for a hospitalized older client with a left hip fracture as a result of a fall at home notices different assessment findings. Which assessment finding warrants immediate intervention by the nurse?
- A. Pain rated 7/10 on the pain scale.
- B. Mild swelling at the fracture site.
- C. Small amount of bleeding from the surgical site.
- D. Left extremity capillary refill greater than 5 seconds.
Correct answer: D
Rationale: The correct answer is D. A left extremity capillary refill greater than 5 seconds indicates poor blood flow to the extremity, which is a sign of compromised circulation. This finding requires immediate intervention by the nurse to prevent complications such as tissue damage or necrosis. Choices A, B, and C are important assessments but do not indicate an immediate need for intervention like the delayed capillary refill in choice D.