HESI LPN
Fundamentals HESI
1. A nurse is evaluating a client’s use of a cane. What is the correct use?
- A. Client holds the cane on the stronger side of the body.
- B. Client holds the cane on the weaker side of the body.
- C. Client holds the cane in front of the weaker side of the body.
- D. Client holds the cane in front of the stronger side of the body.
Correct answer: A
Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.
2. A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a perception from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client's wishes to all members of the multidisciplinary team
Correct answer: D
Rationale: The correct intervention is to communicate the client's wishes to all members of the multidisciplinary team. This action respects the client's autonomy and maintains her comfort by ensuring that her desires regarding visitation and support are known and upheld. Obtaining a perception from the healthcare provider regarding visitation privileges (Choice A) may not fully consider the client's preferences. Requesting a consultation with the ethics committee (Choice B) may be premature and could delay prompt resolution of the issue. Encouraging the client to speak with her husband (Choice C) may not be appropriate, as the husband's demands are disrupting the client's care and comfort, and the client may not feel safe or comfortable doing so.
3. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
- A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
- B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
- C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
- D. Mention, 'Many people with diabetes manage well with insulin injections.'
Correct answer: A
Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.
4. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct answer: A
Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.
5. During a blood transfusion, which observation indicates that the client is experiencing a transfusion reaction?
- A. The client reports feeling warm and flushed.
- B. The client develops a rash on the chest and back.
- C. The client experiences chills and a fever.
- D. The client complains of back pain and shortness of breath.
Correct answer: D
Rationale: Complaints of back pain and shortness of breath are classic signs of a transfusion reaction, specifically indicating a hemolytic reaction. This reaction can lead to the release of hemoglobin into the bloodstream, causing back pain and shortness of breath due to clot formation in the blood vessels, leading to decreased oxygen delivery. Warmth, flushing, rash, chills, and fever are more commonly associated with allergic reactions or febrile non-hemolytic reactions during transfusions. Therefore, options A, B, and C are incorrect in this context.
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