HESI LPN
HESI Fundamentals Study Guide
1. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:
- A. With her hands held lower than her elbows
- B. With her hands held higher than her elbows
- C. With her hands in a fist position
- D. With hands placed on her chest
Correct answer: B
Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.
2. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important instruction the nurse should provide?
- A. Take the medication with a high-fiber meal
- B. Monitor pulse rate daily before taking the medication
- C. Avoid dairy products while on this medication
- D. Discontinue the medication if blurred vision is experienced
Correct answer: B
Rationale: The most important instruction the nurse should provide is to monitor pulse rate daily before taking the medication. Digoxin can lead to bradycardia, so it is crucial to assess the pulse rate before administering the medication. This practice helps ensure that the heart rate is not too low for the safe use of digoxin. Choice A is incorrect as there is no specific requirement to take digoxin with a high-fiber meal. Choice C is also incorrect because there is no need to avoid dairy products while on digoxin. Choice D is incorrect since blurred vision is not a common side effect of digoxin; hence, it is not the most critical instruction to provide.
3. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
- A. Remind the client of the importance of using a rescue inhaler for asthma management
- B. Leave the client alone to process his thoughts about the inhaler
- C. Ask the client what he is thinking about at that moment
- D. Pause and inquire if the client has any questions or needs clarification
Correct answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to ask the client what he is thinking about at that moment. By doing so, the nurse can understand the client's concerns or distractions, which can then be addressed effectively during the teaching session. Option A is incorrect as it assumes the client is not paying attention due to forgetfulness about the importance of the inhaler, which may not be the case. Option B is incorrect because leaving the client alone without addressing the issue does not facilitate effective learning. Option D, although closer, does not directly address the client's distraction and may not uncover the underlying issue causing the lack of focus.
4. A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?
- A. Infection
- B. Dehydration
- C. Urinary retention
- D. Intestinal obstruction
Correct answer: A
Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The bladder mucosa and adjacent tissues being exposed increase the susceptibility to infections. Dehydration (Choice B) is not the primary concern in this condition. Urinary retention (Choice C) is less likely as exstrophy of the bladder usually presents with constant dribbling of urine. Intestinal obstruction (Choice D) is not directly related to exstrophy of the bladder.
5. What is the most common sign of a localized infection?
- A. Fever
- B. Elevated white blood cell count
- C. Redness, warmth, and swelling at the site of infection
- D. Chills and shivering
Correct answer: C
Rationale: The correct answer is C: Redness, warmth, and swelling at the site of infection. These signs are typical indications of a localized infection, representing inflammation and the body's immune response to the pathogen. Fever (choice A) is a systemic response and not specific to a localized infection. Elevated white blood cell count (choice B) can be seen in both localized and systemic infections. Chills and shivering (choice D) are more related to the body's response to fever and not specifically indicative of a localized infection.