HESI LPN
HESI Fundamentals Exam
1. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?
- A. Use gloves to inspect the hair.
- B. Apply a lindane-based shampoo immediately.
- C. Shave the patient's hair off.
- D. Ignore the movement and continue.
Correct answer: A
Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.
2. The healthcare provider is preparing a client with deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test?
- A. Client should be NPO prior to the test
- B. Client should receive a sedative medication before the test
- C. Discontinue anticoagulant therapy before the test
- D. No special preparation is necessary
Correct answer: D
Rationale: No special preparation is required for a Venous Doppler evaluation. Option A is incorrect because there is no need for the client to be NPO (nothing by mouth) before this test. Option B is incorrect as sedative medication is not typically administered for a Venous Doppler evaluation. Option C is incorrect as discontinuing anticoagulant therapy before the test may not be safe for a client with DVT, as it could increase the risk of developing a blood clot. Therefore, the correct answer is D.
3. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?
- A. Folic acid should be taken before and after conception.
- B. Multivitamin supplements are recommended during pregnancy.
- C. A well-balanced diet promotes normal fetal development.
- D. Increased dietary iron improves the health of mother and fetus.
Correct answer: A
Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.
4. A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
- A. Contact the hospital’s spiritual services.
- B. Ask what is making the client cry.
- C. Ensure no visitors or staff enter the room for a short time period.
- D. Turn on the television for a distraction.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.
5. The healthcare provider is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The healthcare provider should monitor for what complication associated with this type of surgery?
- A. Occipital headache
- B. Periorbital crepitus
- C. Expectoration of blood
- D. Changes in vocalization
Correct answer: C
Rationale: Expectoration of blood is a potential complication following SMR surgery, as it may indicate bleeding postoperatively. In contrast, occipital headache (choice A) is not a common complication associated with SMR surgery. Periorbital crepitus (choice B) is more related to facial fractures or certain infections rather than SMR surgery. Changes in vocalization (choice D) are not typically associated with complications following SMR surgery.
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