HESI LPN
Maternity HESI Test Bank
1. When should a nurse on a labor and delivery unit instruct a newly licensed nurse to don gloves for a procedure?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct answer: B
Rationale: The correct answer is B: Performing a newborn's initial bath. Gloves should be worn during this procedure to protect against exposure to body fluids, such as amniotic fluid or blood. Assisting a mother with breastfeeding (Choice A) does not typically require gloves unless there are specific reasons for infection control. Administering vaccines (Choice C) and performing umbilical cord care (Choice D) are procedures that may require hand hygiene but not necessarily gloves, unless there is active bleeding or potential exposure to body fluids. The initial bath involves direct contact with body fluids, making it crucial to wear gloves for protection.
2. What is the primary purpose of a placebo in an experiment?
- A. To reduce the cost of the experiment.
- B. To make the experiment double-blind.
- C. To increase the number of participants.
- D. To serve as a control for comparison with the treatment group.
Correct answer: D
Rationale: The correct answer is D. A placebo serves as a control for comparison with the treatment group, helping to eliminate bias and ensure the results are due to the treatment itself. Placebos are crucial in research to distinguish the actual effect of the treatment from psychological or subjective factors. Choice A is incorrect because the purpose of a placebo is not related to reducing the cost of the experiment. Choice B is incorrect because while placebos are used in double-blind studies, their primary purpose is not to make the experiment double-blind. Choice C is incorrect because the purpose of a placebo is not to increase the number of participants but rather to serve as a comparison group for the treatment being tested.
3. A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
- A. Advocacy ensures clients' safety, health, and rights.
- B. Advocacy involves only supporting client complaints.
- C. Advocacy means making all decisions for the client.
- D. Advocacy is not part of nursing responsibilities.
Correct answer: A
Rationale: The correct answer is A. Advocacy in nursing involves ensuring clients' safety, health, and rights. Nurses advocate for their clients by promoting autonomy, informed decision-making, and protecting their rights. Choice B is incorrect because advocacy goes beyond just supporting client complaints; it encompasses a broader scope of ensuring holistic care and well-being. Choice C is incorrect as advocacy does not mean making all decisions for the client but rather empowering them to make informed choices. Choice D is incorrect as advocacy is a crucial component of nursing responsibilities, as it involves standing up for clients' best interests and ensuring their rights are respected.
4. Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?
- A. Call healthcare provider to request a different analgesic
- B. Determine when morphine can be given again
- C. Implement complementary pain relief methods
- D. Observe dressing to determine the presence of bleeding
Correct answer: C
Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.
5. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?
- A. Place the client on seizure precautions and monitor her frequently.
- B. Take the client's vital signs and notify the physician immediately.
- C. Describe the symptoms to the charge nurse and document them in the client's record.
- D. No action is required at this time as these are known side effects of her medications.
Correct answer: B
Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.