HESI LPN
Fundamentals HESI
1. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
- A. Every 4 to 8 hours
- B. Every 12 to 24 hours
- C. Every 24 to 48 hours
- D. Every 72 to 96 hours
Correct answer: D
Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.
2. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?
- A. Apply a condom catheter.
- B. Apply a skin protectant.
- C. Encourage increased fluid intake.
- D. Assess for bladder distention.
Correct answer: D
Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.
3. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?
- A. Firmly tell the client not to grab
- B. Redirect the client’s attention
- C. Use physical restraints
- D. Avoid contact with the client
Correct answer: B
Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.
4. A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
- A. The nurse opens the sterile field on a wet surface.
- B. The nurse turns away from the sterile field.
- C. The nurse uses a non-sterile glove to touch the sterile field.
- D. The nurse touches the edge of the sterile drape with her hand.
Correct answer: A
Rationale: The correct answer is A. Opening the sterile field on a wet surface contaminates it, rendering it unsafe for use. Moisture can carry microorganisms that can compromise the sterility of the field. Choice B is incorrect because turning away from the sterile field alone does not necessarily contaminate it unless the nurse touches non-sterile items. Choice C is incorrect because using a non-sterile glove to touch the sterile field directly introduces contaminants. Choice D is incorrect as touching the edge of the sterile drape with a hand may not necessarily contaminate the entire field, unlike opening it on a wet surface.
5. A client is 6 hours postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
- A. Allow the client to hear running water while attempting to void
- B. Provide the client with a bedpan while sitting upright
- C. Insert an indwelling urinary catheter and connect it to gravity drainage
- D. Encourage the client to limit fluid intake
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to allow the client to hear running water while attempting to void. This can help stimulate the urge to urinate in a non-invasive way, promoting natural voiding. Providing a bedpan while sitting upright is also a suitable approach to facilitate voiding by encouraging a more natural position. Inserting an indwelling urinary catheter should be a last resort due to infection risks and discomfort associated with catheterization. Encouraging the client to limit fluid intake is not appropriate as hydration is crucial for overall health and can aid in promoting voiding. Therefore, the best initial intervention to promote voiding in this scenario is to allow the client to hear running water.
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