HESI LPN
HESI Fundamentals Study Guide
1. The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?
- A. Directly address the child instead of the mother.
- B. Continue asking the mother questions about the child.
- C. Request another nurse to interview the mother now.
- D. Politely ask the mother to look at you when answering.
Correct answer: B
Rationale: In this scenario, the LPN should continue asking the mother questions about the child. The mother's behavior of looking at the floor may be a cultural practice, such as avoiding direct eye contact, which should be respected. By maintaining the conversation with the mother, the nurse acknowledges and respects her communication style, fostering trust and open dialogue. Option A is not the best choice as it may disregard the cultural context and the importance of the mother's input. Option C is unnecessary as the LPN can effectively handle the situation. Option D could be perceived as insensitive and may disrupt the rapport between the nurse and the mother.
2. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
- A. Remove the catheter and apply direct pressure for 5 minutes.
- B. Initiate intravenous fluids as prescribed.
- C. Secure the catheter using aseptic technique.
- D. Notify the healthcare provider of the need to reposition the catheter.
Correct answer: B
Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.
3. The wound irrigation process cleanses the wound and:
- A. Reduces the potential pain in the wound region or area.
- B. Stops the spread of infection by creating a 'clean' area.
- C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
- D. Allows for the introduction of medications in solution form.
Correct answer: D
Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.
4. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?
- A. Apply antibiotic cream to Child B’s arm immediately
- B. Determine if Child A has a history of Hepatitis C or HIV
- C. Determine the date of Child B’s latest tetanus booster
- D. Wash Child B’s arm thoroughly with soap and water
Correct answer: D
Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.
5. What is the expected date of delivery for a woman whose last menstrual period was on April 20th?
- A. January 20th
- B. January 27th
- C. January 29th
- D. January 31st
Correct answer: B
Rationale: The expected date of delivery is calculated by adding 9 months and 7 days to the last menstrual period. For April 20th, the expected date is January 27th. Therefore, the correct answer is B. Choice A, January 20th, is incorrect as it does not account for the additional 7 days. Choice C, January 29th, and Choice D, January 31st, are also incorrect as they do not consider the standard calculation method for estimating the due date.