HESI LPN
Fundamentals HESI
1. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
- A. Roof of mouth, gums, and inside cheeks
- B. Chewing and inner tooth surfaces
- C. Outer tooth surfaces
- D. Tongue
Correct answer: C
Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.
2. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan?
- A. You will be able to bend at the waist to reach items on the floor in 8 weeks.
- B. Place a pillow between your knees while lying in bed to prevent hip dislocation.
- C. It is safe to use a walker to get out of bed, but you need assistance when walking.
- D. Take pain medication 30 minutes after your physical therapy sessions.
Correct answer: B
Rationale: The correct instruction to include in the teaching plan for a client who had a hemiarthroplasty of the left hip is to 'Place a pillow between your knees while lying in bed to prevent hip dislocation.' This technique helps maintain proper hip alignment and prevents dislocation during the postoperative recovery period. Choice A is incorrect because bending at the waist to reach items on the floor can strain the hip joint and is not recommended following hip surgery. Choice C is incorrect because using a walker alone without assistance can increase the risk of falls and injury, especially in the immediate postoperative period. Choice D is incorrect because pain medication should be taken as prescribed by the healthcare provider, not specifically timed after physical therapy sessions.
3. While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?
- A. Ask the student, 'What did you forget to do?'
- B. Stop and explain why aspiration is needed.
- C. Quietly state, 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'
Correct answer: D
Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.
4. The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to
- A. Approach the healthcare provider and staff nurse for a private meeting to address the situation.
- B. Allow the staff nurse to handle this situation without interference.
- C. Notify other administrative personnel of a breach of professional conduct.
- D. Request an immediate private meeting with the healthcare provider and staff nurse.
Correct answer: D
Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.
5. A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?
- A. Extinguish the fire.
- B. Activate the fire alarm.
- C. Move clients who are nearby.
- D. Close all open doors on the unit.
Correct answer: B
Rationale: In a fire emergency, the nurse's priority is to activate the fire alarm. This action alerts others to the emergency, initiates the evacuation process, and ensures everyone's safety. Extinguishing the fire can be dangerous and should be left to trained personnel. Moving clients who are nearby might delay the activation of the alarm and can put the nurse and clients at risk. Closing all open doors on the unit is important to contain the fire but should not take precedence over alerting others through the fire alarm system.
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