HESI LPN
HESI Fundamentals 2023 Test Bank
1. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client’s wrists before applying the restraints
- B. Tie the restraints to the side rails of the bed
- C. Secure the restraints to the bed frame
- D. Use a quick-release knot to tie the restraints
Correct answer: A
Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.
2. A client with asthma is prescribed a corticosteroid inhaler. Which instruction should the nurse provide to the client to prevent a common side effect of this medication?
- A. Use the inhaler only when experiencing asthma symptoms.
- B. Rinse the mouth with water after using the inhaler.
- C. Increase fluid intake while using the inhaler.
- D. Avoid eating or drinking for 30 minutes after using the inhaler.
Correct answer: B
Rationale: The correct instruction for the client using a corticosteroid inhaler to prevent a common side effect is to rinse the mouth with water after using the inhaler. Corticosteroid inhalers can lead to oral thrush, a fungal infection in the mouth. Rinsing the mouth helps reduce the risk of developing oral thrush. Choices A, C, and D are incorrect because using the inhaler only when experiencing symptoms, increasing fluid intake, or avoiding eating/drinking for 30 minutes after use are not directly related to preventing oral thrush, which is the common side effect associated with corticosteroid inhalers.
3. A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?
- A. Macaroni and cheese
- B. One medium apple with skin
- C. One cup of plain yogurt
- D. Roast chicken and white rice
Correct answer: B
Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.
4. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver's license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next?
- A. Stand to the side of the patient's eye and observe the cornea.
- B. Conclude that the glasses were lost during the accident.
- C. Notify the ambulance personnel about the missing glasses.
- D. Ask the patient where the glasses are.
Correct answer: A
Rationale: In this scenario, the nurse should stand to the side of the patient's eye and observe the cornea. This action is crucial in assessing whether the patient wears contact lenses, especially in unresponsive patients. Observing the cornea can provide valuable information about the patient's eye health and potential use of contact lenses. Choices B, C, and D are incorrect. Concluding that the glasses were lost during the accident is premature without proper assessment. Notifying ambulance personnel about the missing glasses may not be the immediate priority, and asking the unresponsive patient about the glasses would not yield useful information in this situation.
5. A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?
- A. The signature on the preoperative consent form is the client’s
- B. The client understands the risks of the surgery
- C. The client is aware of all postoperative care instructions
- D. The client has no further questions about the surgery
Correct answer: A
Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.
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