HESI LPN
HESI Fundamentals Exam Test Bank
1. What is the most important action for preventing infection in a client with a central venous catheter?
- A. Changing the catheter dressing every 72 hours.
- B. Flushing the catheter with heparin solution daily.
- C. Ensuring the catheter is clamped when not in use.
- D. Maintaining sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.
2. A postoperative client has a prescription for ketorolac 30mg IV q6h. Which response demonstrates that therapeutic levels of the medication have been achieved?
- A. Observe wound drainage for a change in appearance
- B. Assess the client's calves for inflammation
- C. Perform a pain assessment using a numeric scale
- D. Measure the client's intake and output
Correct answer: C
Rationale: The correct response is to perform a pain assessment using a numeric scale. Ketorolac is an NSAID prescribed for pain relief. Monitoring pain levels is crucial to evaluate the therapeutic effectiveness of the medication. Pain assessment helps determine if the medication is providing adequate pain relief, indicating that therapeutic levels have been achieved.
3. A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice, and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct answer: B
Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.
4. A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?
- A. Approach the client and ask if he is hearing voices.
- B. Ignore the behavior as it is common in psychiatric settings.
- C. Encourage the client to express his thoughts verbally.
- D. Observe the client's behavior from a distance.
Correct answer: A
Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.
5. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
- A. Administer the infusion via an infusion pump
- B. Obtain the current serum potassium level
- C. Continuously monitor blood pressure
- D. Teach guided imagery to decrease pain
Correct answer: C
Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.