HESI LPN
HESI Fundamentals 2023 Test Bank
1. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter dressing every 72 hours.
- B. Flush the catheter with heparin solution daily.
- C. Ensure the catheter is clamped when not in use.
- D. Maintain sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.
2. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?
- A. BUN 15 mg/dL
- B. Creatinine 0.8 mg/dL
- C. Sodium 143 mEq/L
- D. Potassium 5.4 mEq/L
Correct answer: D
Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.
3. When evaluating a child with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) for medication management, what is an important assessment for the nurse to perform?
- A. Assess the child's sleep patterns
- B. Assess the child's dietary intake
- C. Assess the child's academic performance
- D. Assess the child's behavior at home
Correct answer: B
Rationale: Assessing the child's dietary intake is crucial as certain foods and additives can affect ADHD symptoms. Ensuring a balanced diet can help manage symptoms and provide proper nutrition. Assessing sleep patterns (Choice A) is also important, but dietary intake is more directly linked to symptom management in ADHD. Academic performance (Choice C) and behavior at home (Choice D) may be affected by ADHD but are not as directly related to medication management as dietary intake.
4. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct answer: B
Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.
5. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will:
- A. Describe a decrease in anxiety using a 1 to 10 anxiety scale.
- B. State the importance of not abruptly stopping the medication.
- C. Not experience dizziness, lightheadedness, or sedation.
- D. Attend scheduled individual and group therapy sessions.
Correct answer: B
Rationale: The correct answer is B. The most important goal of care for a client with generalized anxiety disorder (GAD) taking alprazolam long-term is to ensure they understand the importance of not abruptly stopping the medication. Abruptly stopping benzodiazepines can lead to withdrawal symptoms and potential complications. Choice A is not the most critical goal as the focus should be on the safe continuation of the medication. Choice C is important but not as crucial as preventing abrupt discontinuation. Choice D is beneficial for overall treatment but not the most important goal in this scenario.