HESI LPN
Fundamentals of Nursing HESI
1. A PN is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?
- A. Telfa dressing with antibiotic ointment
- B. Moist sterile non-adherent dressing
- C. Dry sterile dressing that is occlusive
- D. Sterile occlusive pressure dressing
Correct answer: B
Rationale: The correct answer is B: Moist sterile non-adherent dressing. A moist sterile non-adherent dressing is suitable for covering a neural tube defect and would not require further intervention. This type of dressing helps prevent the dressing from sticking to the wound, minimizing trauma during dressing changes. Choice A, Telfa dressing with antibiotic ointment, is not ideal for a neural tube defect as the ointment may not be necessary and can complicate wound care. Choice C, dry sterile dressing that is occlusive, is not recommended for a neural tube defect as it may not provide the necessary environment for proper wound healing. Choice D, sterile occlusive pressure dressing, is excessive for a neural tube defect and may cause unnecessary pressure on the wound site.
2. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?
- A. Assault
- B. False imprisonment
- C. Battery
- D. Libel
Correct answer: C
Rationale: The correct answer is C, 'Battery.' Administering the injection without the client's consent constitutes battery. Assault involves the threat of harm, not the actual act. False imprisonment is restraining a client against their will, which does not apply here. Libel refers to a false written statement, which is not relevant in this scenario.
3. When teaching an adolescent with type 1 diabetes about dietary management, what should the nurse include?
- A. Meals should be eaten at home.
- B. Foods should be weighed using a gram scale.
- C. A ready source of glucose should be available.
- D. Specific foods should be cooked for the adolescent.
Correct answer: C
Rationale: The correct answer is C: A ready source of glucose should be available. When managing type 1 diabetes, it is crucial to have a quick source of glucose readily available in case of hypoglycemia. This ensures that the adolescent can quickly raise their blood sugar levels to prevent complications. Choices A, B, and D are incorrect as they do not address the immediate need for glucose in managing hypoglycemia. While it is important for meals to be consumed regularly and in a controlled manner, specifying that they should be eaten at home or foods weighed using a gram scale is not as critical as ensuring a quick source of glucose in emergency situations.
4. A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of which task?
- A. Loss of control
- B. Insecurity
- C. Dependence
- D. Lack of trust
Correct answer: C
Rationale: A 15-year-old client with a lengthy confining illness is at risk for altered growth and development of the task of dependence. Prolonged illness and confinement can lead to the development of dependence as the individual may become reliant on others for their care and needs. Choices A, B, and D are incorrect in this context. Loss of control, insecurity, and lack of trust are important factors to consider but are not directly related to the altered growth and development task of dependence due to illness and confinement.
5. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?
- A. An x-ray shows the end of the tube above the pylorus.
- B. The tube is aspirated and contains clear gastric fluid.
- C. The tube is flushed with sterile water without resistance.
- D. The client does not cough or choke during tube insertion.
Correct answer: B
Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.