HESI LPN
HESI Fundamentals Study Guide
1. When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?
- A. Check the client for injuries
- B. Call for additional help
- C. Move the client to a sitting position
- D. Assist the client back to bed
Correct answer: A
Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.
2. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
- A. Call the radiology department
- B. Reinsert the implant into the vagina
- C. Apply double gloves to retrieve the implant for disposal
- D. Place the implant in a lead container using long-handled forceps
Correct answer: D
Rationale: The correct action for the nurse to take when finding a radiation implant in the bed is to place the implant in a lead container using long-handled forceps. This action is crucial to minimize radiation exposure to both the patient and healthcare providers and ensure the safe disposal of the radioactive material. Calling the radiology department (choice A) may lead to unnecessary delays in addressing the immediate safety concern. Reinserting the implant into the vagina (choice B) is contraindicated and can cause harm. Applying double gloves to retrieve the implant for disposal (choice C) is not adequate for ensuring proper containment and handling of the radioactive implant, which requires specialized equipment like a lead container and long-handled forceps.
3. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Encourage the client to talk about the underlying fears.
- C. Restrict the client's access to soap and water.
- D. Schedule a time for the client to perform the ritual.
Correct answer: B
Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.
4. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take?
- A. Contact the pharmacy and request the prescribed form of aspirin
- B. Instruct the client about the effects of the medication
- C. Administer the aspirin with a full glass of water or a small snack
- D. Withhold the aspirin until consulting with the healthcare provider
Correct answer: A
Rationale: The correct action for the nurse to take is to contact the pharmacy and request the prescribed form of aspirin. Enteric-coated medications are designed to dissolve in the intestine, not the stomach, to avoid irritation. Therefore, it is essential to ensure the client receives the correct form of aspirin as prescribed. Instructing the client about the effects of the medication (choice B) is not necessary at this point as the issue is related to the form of the aspirin. Administering the aspirin with a full glass of water or a small snack (choice C) is not appropriate as it does not address the need for the correct form of the medication. Withholding the aspirin (choice D) without consulting the healthcare provider is not advisable as it may lead to a delay in the client receiving the necessary medication.
5. To be an effective educator, you should:
- A. listen to people's problems and decide on the approach to meet their needs
- B. select the best strategy for health action for people to implement
- C. direct people's efforts to implement community-based projects
- D. simply tell your clients what to do for their problems/needs
Correct answer: B
Rationale: The correct answer is to select the best strategy for health action for people to implement because it empowers the community to take ownership of their health. Listening to people's problems (Choice A) is important, but the effectiveness lies in empowering them to implement solutions. Directing people's efforts (Choice C) can be directive and may not foster community ownership. Just telling clients what to do (Choice D) does not promote active participation and empowerment.