HESI LPN
Fundamentals HESI
1. Why should a client with an ileal conduit be instructed to empty the collection device frequently?
- A. Force urine to back up into the kidneys.
- B. Suppress production of urine.
- C. Cause the device to pull away from the skin.
- D. Tear the ileal conduit
Correct answer: C
Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.
2. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?
- A. Wheezing
- B. Shortness of breath
- C. Use of accessory muscles
- D. Cough with sputum production
Correct answer: C
Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.
3. A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report?
- A. Where the client ate his breakfast
- B. The times for routine vital sign measurements
- C. The exact times the client had visitors
- D. The type of transmission-based precautions in place
Correct answer: D
Rationale: Information about transmission-based precautions is essential for infection control and continuity of care.
4. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct answer: D
Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.
5. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
- A. Carefully remove the gloves and follow with hand hygiene
- B. Continue with the procedure and clean hands later
- C. Remove the gloves, wash hands, and start over
- D. Use hand sanitizer and continue the procedure
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.
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