HESI LPN
Fundamentals HESI
1. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?
- A. I secure the infant car seat in the back seat facing backwards.
- B. I place my infant in the middle of the living room floor on a blanket to play with my 4-year-old while I make supper in the kitchen.
- C. My sleeping baby looks adorable in the crib with the little buttocks up in the air while the four-year-old naps on the sofa.
- D. I have the 4-year-old hold and help feed the four-month-old a bottle in the kitchen while I make supper.
Correct answer: D
Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.
2. The nurse is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse use to cleanse the pressure ulcer?
- A. Lightly coat the wound with povidone-iodine solution
- B. Irrigate the wound with sterile normal saline
- C. Flush the wound with sterile hydrogen peroxide
- D. Remove the eschar with a wet-to-dry dressing
Correct answer: B
Rationale: Irrigating the wound with sterile normal saline is the correct technique for cleansing a wound when the prescription does not specify a cleaning method. Sterile normal saline is a standard and safe solution that helps to remove debris and promote healing without damaging healthy tissue. Choice A, using povidone-iodine solution, can be cytotoxic and delay wound healing. Choice C, using hydrogen peroxide, can be cytotoxic, cause tissue damage, and delay wound healing. Choice D, using wet-to-dry dressing to remove eschar, is an outdated and non-selective method that can cause trauma to the wound bed and delay healing. Therefore, choice B is the best option for wound cleansing in this scenario.
3. A nurse is providing an in-service about client rights for a group of nurses. Which of the following statements should the nurse include in the service?
- A. A nurse can disclose information to a family member with the client's permission
- B. A nurse can apply restraints on an as-needed basis
- C. A nurse can administer medications without consent to a client as part of a research study
- D. A nurse is responsible for informing clients about treatment options
Correct answer: A
Rationale: The correct statement to include in the in-service about client rights is that a nurse can disclose information to a family member with the client's permission. This respects the client's autonomy and privacy. Choice B is incorrect because restraints should only be applied based on a specific assessment and order, not on an as-needed basis. Choice C is incorrect as administering medications without consent is a violation of ethical principles and legal standards. Choice D is incorrect because while nurses should educate clients about treatment options, the ultimate decision lies with the client after being informed.
4. When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby. What is the best response for the nurse to give?
- A. The baby is protected by the sac. Sex is perfectly alright.
- B. It is unlikely to harm the baby. What you do with your personal life is your concern.
- C. Intercourse during pregnancy is usually alright, but you need to ask the doctor if it is acceptable for you.
- D. In a normal pregnancy, intercourse will not harm the baby. However, many women experience a change in desire. How are you feeling?
Correct answer: D
Rationale: Choice D is the best response as it reassures the patient that intercourse in a normal pregnancy will not harm the baby. It also shows empathy by acknowledging that many women experience changes in sexual desire during pregnancy. This response validates the patient's concerns and opens up a dialogue about her feelings. Choice A is incorrect as it lacks information about changes in sexual desire and oversimplifies the situation. Choice B is dismissive of the patient's concerns and does not provide adequate information. Choice C is not the best response as it suggests asking the doctor without offering immediate reassurance or addressing the patient's worries.
5. An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client’s spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?
- A. Reassure the spouse that the client will be well cared for and provide information about the facility’s care practices.
- B. Inform the spouse that care will be adjusted based on the client’s condition and needs.
- C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
- D. Suggest that the spouse speak with other family members for reassurance.
Correct answer: A
Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility’s care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.