HESI LPN
HESI Fundamentals 2023 Test Bank
1. What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?
- A. Allow visitors with precautions in place
- B. Wear sterile gloves when handling the client's body fluid
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.
2. A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?
- A. Follow the prompts of the AED
- B. Apply the AED pads to the client’s chest
- C. Wipe the client’s chest dry
- D. Move the client from the bathroom
Correct answer: B
Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.
3. What term is used to describe each member of a pair of genes?
- A. allele
- B. zygote
- C. autosome
- D. node
Correct answer: A
Rationale: The correct answer is 'allele.' An allele refers to one of two or more versions of a gene located at the same position on a chromosome. In genetics, alleles are responsible for variations in inherited traits. Choice B, 'zygote,' is incorrect as a zygote is a fertilized egg cell formed by the fusion of two gametes. Choice C, 'autosome,' is incorrect as autosomes are non-sex chromosomes that determine an individual's genetic traits excluding sex-linked characteristics. Choice D, 'node,' is incorrect as it does not relate to the concept of genes or genetic inheritance.
4. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?
- A. Explain the importance of bathing or showering daily
- B. Encourage fluid intake of at least 2,000 ml daily
- C. Keep the legs covered as much as possible
- D. Apply emollient to the affected area at least twice daily
Correct answer: D
Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.
5. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?
- A. A nurse tied a client's restraints straps to the moveable part of the bed frame.
- B. An assistive personnel placed a surgical mask on a client who has TB before transporting her to radiology.
- C. A nurse administered a medication to a client 30 minutes before the dose is due.
- D. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.
Correct answer: C
Rationale: The correct answer is C. An incident report should be completed when a nurse administers medication to a client significantly earlier than the scheduled time. This deviation from the prescribed schedule could potentially impact the client's treatment plan and requires documentation for proper evaluation and follow-up. Choices A, B, and D do not necessarily require an incident report. Choice A involves improper restraint application, which is a safety issue but does not directly involve medication administration. Choice B involves a protective measure for a client with TB, which is within the scope of practice for assistive personnel. Choice D describes an increase in IV fluid administration, which may need monitoring but does not necessarily indicate a need for an incident report unless there are specific complications or adverse effects related to the additional fluid.