HESI LPN
HESI Fundamentals Exam
1. A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
- A. Cough deeply after each use.
- B. Take a deep breath and hold for 10 seconds.
- C. Breathe in slowly and deeply to raise the ball or piston.
- D. Exhale forcefully before using the spirometer.
Correct answer: C
Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.
2. When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
- A. Press gently on the tragus of the client’s ear.
- B. Pull the ear lobe up and back.
- C. Insert the medication deeply into the ear canal.
- D. Massage the ear gently after administering the medication.
Correct answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client’s ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.
3. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?
- A. Notify the provider about the client's decision
- B. Proceed with the transport
- C. Prepare the surgical site
- D. Document the client’s statement
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.
4. The healthcare provider is caring for a patient who has multiple ticks on lower legs and body. What should the healthcare provider do to rid the patient of ticks?
- A. Use blunt tweezers and pull upward with steady pressure.
- B. Burn the ticks with a match or a small lighter.
- C. Allow the ticks to drop off by themselves.
- D. Apply miconazole and cover with plastic.
Correct answer: A
Rationale: Correct answer: When removing ticks, it is essential to use blunt tweezers to grasp the tick as close to the head as possible and pull upward with even, steady pressure to remove the entire tick. Option B is incorrect because burning ticks can increase the risk of infection and is not recommended. Option C is incorrect as waiting for ticks to drop off by themselves prolongs potential exposure to tick-borne diseases. Option D is incorrect as miconazole is an antifungal medication and not used for tick removal.
5. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Provide supplemental oxygen
- D. Assess the client's respiratory rate
Correct answer: A
Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.
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