HESI LPN
Fundamentals HESI
1. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
- A. May result in charges of unlawful seclusion and restraint
- B. Leaves the nurse vulnerable to charges of assault and battery
- C. Was appropriate given the client's history of violence
- D. Was necessary to maintain the therapeutic milieu of the unit
Correct answer: A
Rationale: Seclusion should only be used when necessary and with proper documentation; otherwise, it may be considered unlawful. Placing a client in seclusion without a clear indication or proper documentation could lead to legal ramifications, making choice A the correct answer. Choice B is incorrect because assault and battery do not apply in this scenario. Choice C is incorrect as there is no mention of the client posing an imminent threat due to a history of violence. Choice D is incorrect as seclusion should not be used solely to maintain the therapeutic milieu but rather for the safety of the client and others.
2. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
- A. The family member washes out the feeding bag with warm water once every 24 hours.
- B. The family member washes out the feeding bag with hot water once every 24 hours.
- C. The family member washes out the feeding bag with soap and water every 24 hours.
- D. The family member changes the feeding bag every 24 hours.
Correct answer: A
Rationale: The correct answer is A. Washing out the feeding bag with warm water once every 24 hours is not sufficient to prevent bacterial growth and can lead to diarrhea. Using hot water may damage the feeding bag. Washing out the feeding bag with soap and water every 24 hours is excessive and may leave residue that could be harmful. Changing the feeding bag every 24 hours is important for preventing infections but does not directly address the issue of diarrhea in this case.
3. The healthcare provider is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...
- A. Notify the surgeon of the client’s concern
- B. Have the client sign a new surgical permit
- C. Add the client’s concern to the permit
- D. Inform the surgeon about the client’s concern
Correct answer: D
Rationale: In this scenario, the best course of action is to inform the surgeon about the client's concern. This action ensures that the surgeon is aware of the client's specific request or concern related to the procedure. By directly involving the surgeon, the client's preferences or needs can be addressed effectively, potentially avoiding any misunderstanding or dissatisfaction. Choice A has been corrected to 'Notify the surgeon of the client’s concern' as the operating room staff may not have the authority to make changes to the permit. Having the client sign a new surgical permit (Choice B) may not be necessary if the concern can be addressed by informing the surgeon, making Choice B less efficient. Adding the client’s concern to the permit (Choice C) without consulting the surgeon may not align with the standard procedure and could lead to confusion or legal issues if the surgeon is not aware of the client’s specific requests.
4. When ethical dilemmas arise, what should newly licensed nurses expect and identify as an ethical dilemma?
- A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment.
- B. A nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints.
- C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.
- D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.
Correct answer: C
Rationale: An ethical dilemma involves a situation where there are conflicting values or principles that make it difficult to make a clear decision. In the given scenarios, option C best represents an ethical dilemma as the family has conflicting feelings about initiating enteral tube feedings for their terminally ill father. This situation presents a clash between different values and beliefs, making it challenging to reach a resolution. Options A, B, and D do not illustrate conflicting values or principles that characterize an ethical dilemma. Option A describes a nurse's impairment, which is a concern but not a direct ethical dilemma. Option B depicts a potential breach of client autonomy and restraint use, which is an ethical issue but not a true ethical dilemma. Option D involves a client's personal decision regarding a durable power of attorney form, which, although important, does not present conflicting values or principles that define an ethical dilemma.
5. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
- A. Monitor the client for pain in the suprapubic region.
- B. Ensure the client is free of metal objects.
- C. Administer 240 mL (8 oz) of oral contrast before the procedure.
- D. Assist the client with a bowel cleansing.
Correct answer: B
Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.
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