HESI LPN
HESI Fundamentals 2023 Test Bank
1. When a client files a lawsuit against an LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:
- A. Evidence
- B. Tort discovery
- C. Proximate cause
- D. Common cause
Correct answer: C
Rationale: The correct answer is C, 'Proximate cause.' Proximate cause establishes the link between the harm suffered and the negligent actions performed by the nurse. In a malpractice lawsuit, proving proximate cause is essential to demonstrate that the nurse's actions directly led to the harm experienced by the client. Choice A, 'Evidence,' is incorrect as evidence is the information presented to support or refute a claim, not specifically the link between harm and negligence. Choice B, 'Tort discovery,' is incorrect as it does not specifically refer to establishing the link between harm and negligence. Choice D, 'Common cause,' is incorrect as it does not capture the legal concept of proximate cause in establishing liability in malpractice cases.
2. A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:
- A. Purulent
- B. Serous
- C. Sanguineous
- D. Serosanguineous
Correct answer: A
Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.
3. A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
4. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?
- A. In the morning upon rising.
- B. Immediately after the client eats breakfast.
- C. Before the client goes to bed.
- D. After the client has had a drink of water.
Correct answer: A
Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.
5. In an emergency department, a nurse is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?
- A. Auscultate bowel sounds.
- B. Administer an antiemetic.
- C. Offer pain medication.
- D. Palpate the abdomen.
Correct answer: A
Rationale: The correct action the nurse should take first is to auscultate bowel sounds. This step is crucial to assess bowel activity before proceeding with palpation or administering medications. Assessing bowel sounds can provide valuable information about bowel motility and potential obstructions. Administering an antiemetic or offering pain medication may be necessary but should come after assessing bowel sounds to ensure appropriate treatment. Palpating the abdomen should be avoided initially to prevent potential discomfort or complications, especially if there is suspected abdominal pathology.
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