HESI LPN
Fundamentals HESI
1. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
- A. Airway
- B. Blood pressure
- C. Surgical site
- D. Level of consciousness
Correct answer: A
Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.
2. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?
- A. It is contagious with frequent recurrences.
- B. It is most helpful to air-dry feet after bathing.
- C. It is treated with salicylic acid.
- D. It is caused by lice.
Correct answer: A
Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.
3. A healthcare provider has inserted an indwelling catheter for a male patient. Where should the healthcare provider tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?
- A. Lower abdomen
- B. Upper thigh
- C. Penoscrotal junction
- D. Mid-abdomen
Correct answer: A
Rationale: Taping the catheter to the lower abdomen is the correct placement to prevent pressure on the urethra at the penoscrotal junction. Securing the catheter at the lower abdomen helps in reducing discomfort and minimizes the risk of trauma to the urethra. Placing the catheter on the upper thigh or penoscrotal junction can lead to tension on the catheter and potential discomfort for the patient. Taping the catheter to the mid-abdomen is not recommended as it does not provide the necessary support to prevent pressure on the urethra at the penoscrotal junction.
4. A healthcare professional is reviewing a client's health record and notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?
- A. Single
- B. Stat
- C. Routine
- D. Now
Correct answer: C
Rationale: A routine prescription, such as lisinopril 10 mg PO once daily, is administered on a regular schedule with or without a termination date. It is a standard, ongoing prescription for maintenance therapy. Choice A, 'Single,' would typically refer to a one-time prescription. Choice B, 'Stat,' is used for prescriptions that are needed immediately or in emergency situations. Choice D, 'Now,' is not a common prescription type designation and is not applicable in this context.
5. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter dressing every 72 hours.
- B. Flush the catheter with heparin solution daily.
- C. Ensure the catheter is clamped when not in use.
- D. Maintain sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.
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