HESI LPN
Fundamentals of Nursing HESI
1. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?
- A. Make sure two fingers can fit under the sleeve.
- B. Apply the sleeve tightly to prevent blood clots.
- C. Ensure the sleeve is snug and comfortable.
- D. Check that the sleeve is loose enough to avoid constriction.
Correct answer: A
Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.
2. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?
- A. Remove small objects from the floor.
- B. Cover electric outlets with safety plugs.
- C. Remove toxic substances from low areas.
- D. Test the temperature of water before bathing.
Correct answer: D
Rationale: Testing the temperature of water before bathing is crucial to prevent burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can easily be burned by water that is too hot. Testing the water temperature before bathing ensures that the water is at a safe and comfortable level for the infant. While choices A, B, and C are also important in accident prevention, such as reducing choking hazards, preventing electric shocks, and avoiding poisoning, testing the water temperature before bathing is the most immediate and direct action to prevent harm to the infant during bathing.
3. A client is being successfully treated with clozapine (Clozaril). Which of the following statements by the client reflects a need for further teaching about managing the drug's adverse effects?
- A. If I eat too many fruits, I'll get constipated.
- B. I need to take the medicine with food to avoid nausea.
- C. I have to get up slowly so I don't get dizzy.
- D. Sometimes I have to push myself because I'm sleepy.
Correct answer: A
Rationale: Choice A reflects a need for further teaching as the client mistakenly believes that eating too many fruits causes constipation, showing a misunderstanding about dietary fiber's role in preventing constipation. Choices B, C, and D demonstrate accurate understanding of managing clozapine's adverse effects, such as taking it with food to avoid nausea, getting up slowly to prevent dizziness, and pushing oneself when feeling sleepy.
4. What is the most common method of attempted suicide?
- A. Hanging
- B. Drug overdose
- C. Gunshot
- D. Slashing the wrists
Correct answer: B
Rationale: Drug overdose is the most common method of attempted suicide. While hanging, gunshot, and slashing the wrists are also methods used in suicide attempts, statistics show that drug overdose is the most prevalent method chosen by individuals attempting suicide. Hanging, gunshot, and slashing the wrists are indeed common methods as well, but drug overdose ranks highest in terms of frequency.
5. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?
- A. Capillary refill less than 3 seconds
- B. 1+ pitting edema in both feet
- C. Pale nail beds in both hands
- D. Thick skin on the soles of the feet
Correct answer: A
Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.