HESI LPN
Fundamentals of Nursing HESI
1. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?
- A. Call the Poison Control Center as soon as the situation is identified
- B. Empty the child's mouth in any case of possible poisoning
- C. Have the child move minimally if a toxic substance was inhaled
- D. Do not induce vomiting if the poison is a hydrocarbon
Correct answer: B
Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.
2. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?
- A. Carry a client's soiled linens out of the room in a mesh linen bag
- B. Place a client who has tuberculosis in a room with negative-pressure airflow
- C. Provide disposable plates and utensils for a client who is HIV-positive
- D. Dispose of a client's blood-saturated dressing in a biohazard bag
Correct answer: B
Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.
3. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?
- A. Corn pads are an adequate treatment and should be continued.
- B. The patient should avoid soaking the feet before using a pumice stone.
- C. The current self-treatment is likely impeding circulation to the toes.
- D. Tighter shoes would help compress the corns and make them smaller.
Correct answer: C
Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.
4. When caring for a client with a tracheostomy, which of the following actions should the nurse take?
- A. Clean the skin around the stoma with normal saline.
- B. Secure the tracheostomy ties with two fingers' width underneath.
- C. Soak the outer cannula in warm tap water.
- D. Use a cotton tip applicator to clean the inside of the inner cannula.
Correct answer: A
Rationale: When caring for a client with a tracheostomy, the nurse should clean the skin around the stoma with normal saline to prevent infection and ensure cleanliness. This action helps in maintaining skin integrity and preventing skin breakdown. Securing the tracheostomy ties with two fingers' width underneath is essential to allow for proper fit, prevent skin irritation, and ensure the ties are not too tight. Soaking the outer cannula in warm tap water is not recommended as it can lead to contamination and is not a standard practice. Using a cotton tip applicator to clean the inside of the inner cannula is discouraged as it can leave fibers behind, increasing the risk of aspiration and respiratory complications.
5. While auscultating the anterior chest of a newly admitted patient, what would the nurse expect to hear?
- A. Normal breathing sounds
- B. Wheezing
- C. Crackles
- D. Stridor
Correct answer: A
Rationale: When auscultating the chest, normal breathing sounds are expected in a healthy individual. Wheezing is a high-pitched whistling sound that indicates narrowed airways and is often heard in conditions like asthma. Crackles are fine, crackling sounds heard on inspiration or expiration and are associated with conditions like pneumonia or heart failure. Stridor is a high-pitched, harsh sound heard during inspiration due to upper airway obstruction. Therefore, choices B, C, and D indicate abnormal respiratory findings, while choice A signifies normal breathing sounds.
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