HESI LPN
HESI Fundamentals Exam Test Bank
1. A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?
- A. Adolescent
- B. Preschooler
- C. Older adult
- D. Adult
Correct answer: B
Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.
2. A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?
- A. Montgomery straps
- B. Sterile gauze
- C. Adhesive tape
- D. Elastic bandages
Correct answer: A
Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.
3. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
- A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
- B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
- C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
- D. Mention, 'Many people with diabetes manage well with insulin injections.'
Correct answer: A
Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.
4. A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
- A. the medication
- B. the route
- C. the dose
- D. the frequency
Correct answer: C
Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.
5. A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?
- A. Keep the client's bed in the lowest position.
- B. Encourage the client to wear non-slip socks.
- C. Place a fall risk sign on the client's door.
- D. Use a gait belt when ambulating the client.
Correct answer: A
Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.
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