HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?
- A. Using a sterile technique
- B. Ensuring correct placement of the CVC
- C. Flushing the CVC with saline after administration
- D. Monitoring for signs of infection
Correct answer: B
Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.
2. In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:
- A. Will you briefly summarize your point because others need time as well?
- B. Your behavior is obnoxious and drains the group.
- C. I am so frustrated with your behavior.
- D. To ignore the behavior and allow him to vent
Correct answer: A
Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.
3. While caring for a client with an AV fistula in the left forearm, the PN observed a palpable buzzing sensation over the fistula. What action should the PN take?
- A. Loosen the fistula dressing
- B. Report the presence of a bounding pulse
- C. Document that the fistula is intact
- D. Apply gentle pressure over the site
Correct answer: C
Rationale: A palpable buzzing sensation, known as a thrill, over an AV fistula indicates proper functioning. The correct action for the PN is to document that the fistula is intact. Choice A is incorrect because there is no need to loosen the fistula dressing when the thrill is felt. Choice B is incorrect as a bounding pulse is not related to the observed buzzing sensation. Choice D is incorrect because applying pressure is unnecessary when a thrill is present, indicating proper AV fistula function.
4. Which action should the PN implement when using standard precautions to provide client care?
- A. Apply sterile gloves to obtain a finger stick blood sample
- B. Wear clean exam gloves to perform perineal catheter care
- C. Replace the needle cap after giving an intramuscular injection
- D. Wear a paper gown to prevent transmission of droplet pathogens
Correct answer: B
Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.
5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?
- A. Droplet precautions
- B. Contact precautions
- C. Airborne precautions
- D. Standard precautions
Correct answer: C
Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.
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