HESI LPN
Practice HESI Fundamentals Exam
1. A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?
- A. Offer to assist the client who needs the bedpan.
- B. Administer the injection the other nurse prepared.
- C. Prepare another syringe and administer the injection.
- D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.
Correct answer: C
Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.
2. The UAP reports to the nurse that a client refused to bathe for the third consecutive day. Which action is best for the nurse to take?
- A. Explain the importance of good hygiene to the client
- B. Ask family members to encourage the client to bathe
- C. Reschedule the bath for the following day
- D. Ask the client why the bath was refused
Correct answer: D
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reason for refusal is crucial in identifying and addressing any underlying concerns or issues that may be contributing to the refusal. This approach promotes open communication, client-centered care, and helps in developing a plan of care that is tailored to the client's needs and preferences. Choices A, B, and C do not directly address the root cause of the refusal and may not effectively resolve the situation.
3. In the emergency department, a child is admitted for accidental ingestion of a poison. The practical nurse (PN) should know that inducing vomiting is recommended for which child?
- A. An 8-month-old who ingested four to six ibuprofen tablets
- B. A 3-year-old who drank an unknown amount of charcoal lighter fluid
- C. A 16-month-old who ingested 2 ounces of acetaminophen elixir
- D. A 2-year-old who ate a handful of automatic dishwasher detergent
Correct answer: C
Rationale: Inducing emesis is recommended for the child who ingested a large dose of acetaminophen elixir because this medication is hepatotoxic. Acetaminophen overdose can lead to severe liver damage, and prompt removal from the stomach can help reduce absorption and potential harm.
4. A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)
- A. Encourage oral fluid intake of 3,000 ml/day
- B. Observe for evidence of hypokalemia
- C. Teach the client how to restrict dietary sodium
- D. Monitor PTT, PT, and INR lab values
Correct answer: B
Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.
5. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:
- A. Cleanse the entry port prior to withdrawing urine.
- B. Use a sterile syringe to collect urine from the collection bag.
- C. Obtain the specimen from the drainage tubing.
- D. Replace the catheter before obtaining the specimen.
Correct answer: A
Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.