HESI LPN
HESI Fundamentals Test Bank
1. While changing the linen on the client's bed, what should the nurse do?
- A. Hold the linen away from their body and clothing.
- B. Fold the linen neatly before placing it in the laundry.
- C. Wear clean gloves while handling the linen.
- D. Place the linen directly on the floor until the new linen is in place.
Correct answer: A
Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.
2. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses a brush to scrub under her nails.
- C. The nurse washes for at least 30 seconds.
- D. The nurse uses alcohol-based hand rub only.
Correct answer: A
Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.
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. The healthcare professional is evaluating the body alignment of a patient in the sitting position. Which observation will indicate a normal finding?
- A. The edge of the seat is making contact with the popliteal space.
- B. Both feet are supported on the floor with ankles flexed.
- C. The body weight is solely on the buttocks.
- D. The arms hang comfortably at the sides.
Correct answer: B
Rationale: In a normal sitting position, both feet should be supported on the floor with the ankles comfortably flexed. This position helps in maintaining stability and proper alignment. Choice A is incorrect because the edge of the seat pressing against the popliteal space may cause discomfort and is not indicative of proper alignment. Choice C is incorrect as the body weight should be evenly distributed for proper alignment and comfort, not solely on the buttocks. Choice D is incorrect as the position of the arms alone does not indicate proper body alignment in the sitting position; proper arm positioning is important for comfort but not a key indicator of body alignment.
5. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?
- A. “I will set my water heater at 130°F.”
- B. “Once my baby can sit up, they should be safe in the bathtub.”
- C. “I will place my baby on their stomach to sleep.”
- D. “Once my infant starts to push up, I will remove the mobile from over the crib.”
Correct answer: D
Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.
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