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 healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?
- A. Assess the client for orthostatic hypotension
- B. Obtain a gait belt
- C. Ensure the client has proper footwear
- D. Ask the client to perform range-of-motion exercises
Correct answer: A
Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.
3. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
- A. "I'm having mild pain."
- B. "The pain is like a dull ache in my stomach."
- C. "I notice that the pain gets worse after I eat."
- D. "The pain makes me feel nauseous."
Correct answer: B
Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.
4. What is the first step a healthcare professional should take when preparing to provide tracheostomy care?
- A. Perform hand hygiene
- B. Gather equipment
- C. Explain the procedure
- D. Assess the client
Correct answer: A
Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.
5. The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?
- A. It is contagious with frequent recurrences.
- B. It is most helpful to air-dry feet after bathing.
- C. It is treated with salicylic acid.
- D. It is caused by lice.
Correct answer: A
Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.
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