HESI LPN
Fundamentals HESI
1. 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.
2. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?
- A. ''I am going to listen to your abdomen.''
- B. ''You need to wait until the surgeon evaluates your condition.''
- C. ''You can have clear liquids, but let me check with the surgeon first.''
- D. ''It is best to start with small sips of clear liquids and observe how you feel.''
Correct answer: A
Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client’s gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.
3. When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
- A. The area around the infusion site feels warm to the touch.
- B. The infusion site is swollen and cool to the touch.
- C. The infusion line does not flush properly.
- D. There is no blood return in the infusion line.
Correct answer: A
Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.
4. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
- A. Dyspnea
- B. Heart murmur
- C. Macular rash
- D. Hemorrhage
Correct answer: B
Rationale: A new or changed heart murmur is a common sign of valve involvement in infective endocarditis, indicating a complication such as valve damage or regurgitation. Dyspnea is more commonly associated with respiratory or cardiac conditions not directly related to infective endocarditis. A macular rash is not a typical symptom of infective endocarditis, suggesting other conditions like infectious diseases. Hemorrhage is not a direct complication of infective endocarditis but may occur due to factors such as anticoagulant therapy or underlying bleeding disorders.
5. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:
- A. Check the client’s identification bracelet
- B. Inform the client about the procedure
- C. Prepare the client for transport
- D. Verify the x-ray order
Correct answer: A
Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.
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