HESI LPN
HESI Fundamentals Exam
1. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?
- A. Supine position
- B. Lateral position
- C. Lateral position with positioning supports
- D. Supine position with no pillow under the patient's head
Correct answer: B
Rationale: When assessing body alignment for an immobilized patient, the nurse should use the lateral position. This position helps in assessing alignment and preventing complications such as pressure ulcers. The supine position (Choice A) may not provide an accurate assessment of body alignment in an immobilized patient. While a lateral position with positioning supports (Choice C) may be used for comfort, it is not specifically for assessing body alignment. Using the supine position without a pillow under the patient's head (Choice D) is not ideal for assessing body alignment in an immobilized patient as it may not accurately reflect the patient's overall alignment.
2. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?
- A. Use gentle suction to prevent tissue damage.
- B. Instruct the patient to blow their nose forcefully to clear the passage.
- C. Place a dry washcloth under the nose to absorb secretions.
- D. Insert a cotton-tipped applicator into the back of the nose.
Correct answer: A
Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.
3. The healthcare provider is caring for a client with a wound infection. Which type of dressing is most appropriate to use to promote healing by secondary intention?
- A. Dry gauze dressing
- B. Wet-to-dry dressing
- C. Transparent film dressing
- D. Hydrocolloid dressing
Correct answer: D
Rationale: Hydrocolloid dressings are ideal for promoting healing by secondary intention in wound infections. These dressings create a moist environment that supports autolytic debridement and facilitates the healing process. Dry gauze dressings (Option A) may lead to adherence, causing trauma upon removal and disrupting the wound bed. Wet-to-dry dressings (Option B) are primarily used for mechanical debridement and can be painful during dressing changes. Transparent film dressings (Option C) are more suitable for superficial wounds with minimal exudate and are not typically used for wound infections requiring healing by secondary intention.
4. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?
- A. Administer pain medication 45 minutes prior to dressing change.
- B. Change the dressing quickly to minimize pain.
- C. Provide reassurance to the client that the pain will pass.
- D. Use a less painful dressing technique.
Correct answer: A
Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.
5. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
- A. Ask, 'Tell me more about how your friends discourage you.'
- B. Say, 'Your friends should support you, not discourage you.'
- C. Respond, 'It sounds like your friends are not supportive.'
- D. Suggest, 'You need to focus on your treatment plans regardless of your friends.'
Correct answer: A
Rationale: The correct approach for the nurse is to ask the client to elaborate on how their friends discourage them. By doing so, the nurse shows empathy, encourages the client to express their feelings, and gains insight into the situation. This open-ended question can help the nurse understand the specific issues the client is facing and work towards finding solutions collaboratively. Choices B, C, and D do not effectively address the client's concerns or encourage further discussion. Choice B is directive and may come off as judgmental, choice C assumes the friends are not supportive without exploring further, and choice D dismisses the client's feelings and the impact of peer influence.
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