HESI LPN
HESI Fundamentals 2023 Quizlet
1. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in a Sim's position with the weight on the anterior ilium.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct answer: C
Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.
2. While changing the linen on the client's bed, what should the nurse do?
- A. Hold the linen away from their body and clothing.
- B. Fold the linen neatly before placing it in the laundry.
- C. Wear clean gloves while handling the linen.
- D. Place the linen directly on the floor until the new linen is in place.
Correct answer: A
Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.
3. A client with a diagnosis of schizophrenia is prescribed risperidone. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: When a client is prescribed risperidone, it is essential to monitor for potential side effects. Weight gain is a common side effect of risperidone, so the nurse should closely monitor the client's weight throughout the treatment. This monitoring helps in early detection of weight changes and allows for timely interventions to prevent further complications.
4. When conducting an admission assessment, the LPN should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?
- A. Complementary healing practices interfere with the efficacy of the medical model of treatment.
- B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
- C. Many complementary healing practices can be used in conjunction with conventional practices.
- D. Conventional medical practices will ultimately replace the use of complementary healing practices.
Correct answer: C
Rationale: When considering the use of complementary healing practices, it is important to acknowledge that many of these practices can be safely integrated with conventional treatments to provide holistic care. Choice A is incorrect because complementary healing practices can complement traditional medical approaches rather than interfere with their efficacy. Choice B is incorrect as interactions between conventional medications and folk remedies may vary, but not all interactions lead to adverse effects. Choice D is incorrect as conventional medical practices and complementary healing practices can coexist and each offer benefits in healthcare.
5. What is the most important action for preventing infection in a client with a central venous catheter?
- A. Changing the catheter dressing every 72 hours.
- B. Flushing the catheter with heparin solution daily.
- C. Ensuring the catheter is clamped when not in use.
- D. Maintaining sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.