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. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?
- A. The parents' name and telephone number
- B. The currency of the immunization and allergy history of the child
- C. The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
- D. The affected child's age and weight
Correct answer: D
Rationale: In the event of accidental poisoning, it is crucial to know the child's age and weight to determine the appropriate treatment. This information helps healthcare providers calculate the correct dosage of antidotes or medications needed based on the child's size and age. The child's age and weight play a significant role in managing accidental poisoning cases. Therefore, this information should be a priority for parents to communicate in such emergencies. Choices A, B, and C are not as critical as the child's age and weight when it comes to immediate treatment decisions for accidental poisoning.
3. A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?
- A. Supine and low Fowler's position
- B. Right lateral in Trendelenburg position
- C. Side lying with the right side of the chest elevated
- D. Prone with pillows under the extremities
Correct answer: B
Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.
4. A client has a closed wound drainage system. Which of the following actions should the nurse take?
- A. Avoid pressing the container down to create a vacuum
- B. Wear sterile gloves while handling the drainage system
- C. Reset the container with the drainage port closed
- D. Maintain the drain in a dependent position to facilitate drainage
Correct answer: D
Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.
5. A nurse is caring for a postoperative client following knee arthroplasty who requires thigh-high compression sleeves. What should the nurse do?
- A. Make sure two fingers can fit under the sleeve.
- B. Apply the sleeve tightly to prevent blood clots.
- C. Ensure the sleeve is snug and comfortable.
- D. Check that the sleeve is loose enough to avoid constriction.
Correct answer: A
Rationale: The correct answer is to make sure two fingers can fit under the sleeve. This allows for proper circulation and ensures that the sleeve is not too tight, which can lead to complications such as impaired blood flow or tissue damage. Choice B is incorrect because applying the sleeve tightly can actually cause harm rather than prevent blood clots. Choice C is incorrect as snugness alone may not guarantee proper fit. Choice D is incorrect as a sleeve that is too loose can be ineffective in providing the necessary compression.
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