HESI LPN
HESI Fundamentals Exam Test Bank
1. When preparing to apply dressing to a stage 2 pressure injury, which type of dressing should the nurse use?
- A. Hydrocolloid
- B. Gauze
- C. Transparent film
- D. Alginate
Correct answer: A
Rationale: The correct answer is A: Hydrocolloid. Hydrocolloid dressings are recommended for stage 2 pressure injuries as they help maintain a moist wound environment, which supports the healing process. Gauze (choice B) is not ideal for stage 2 pressure injuries as it can stick to the wound bed and disrupt the healing process. Transparent film dressings (choice C) are more suitable for superficial wounds or as a secondary dressing. Alginate dressings (choice D) are typically used for wounds with heavy exudate, which is not typically seen in stage 2 pressure injuries.
2. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?
- A. allow the head to deliver and check for the location of the cord
- B. advise your partner to stop the ambulance and assist with the delivery
- C. tell the mother to take short, quick breaths until you arrive at the hospital
- D. prepare the mother for an emergency delivery and open the obstetrics kit
Correct answer: B
Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.
3. A 15-month-old child with the diagnosis of hydrocephalus is scheduled for a computed tomography (CT) scan. What should the nurse include when preparing the toddler for the CT scan?
- A. Shaving the head
- B. Starting the prescribed IV infusion
- C. Administering the prescribed sedative
- D. Giving the child a simple explanation of the procedure
Correct answer: D
Rationale: Preparing a toddler for a CT scan involves providing a simple explanation of the procedure to reduce anxiety and help the child understand what will happen. This approach helps establish trust and cooperation, making the experience less frightening for the child. Shaving the head, starting an IV infusion, or administering a sedative are not typically part of the preparation for a CT scan in a toddler and may not be necessary or appropriate in this scenario.
4. While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?
- A. Lower the client to the floor and place a pad under the client's head.
- B. Hold the client's head still to prevent injury.
- C. Restrain the client to prevent movement.
- D. Place the client in a supine position.
Correct answer: A
Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.
5. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?
- A. Increased appetite
- B. Dry mouth
- C. Nausea and vomiting
- D. Gingival hyperplasia
Correct answer: D
Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.