HESI LPN
Fundamentals HESI
1. A client is receiving discharge teaching about a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?
- A. I should avoid foods high in potassium while taking this medication.
- B. I will check my pulse before taking the medication.
- C. I should avoid taking antacids simultaneously with this medication.
- D. I will take the medication at the same time every day.
Correct answer: A
Rationale: The correct answer is A because clients taking digoxin should avoid foods high in potassium. High potassium levels can potentiate the effects of digoxin, leading to toxicity. Choices B, C, and D are correct statements regarding digoxin administration. Checking the pulse before taking the medication helps monitor for signs of digoxin toxicity. Avoiding taking antacids simultaneously prevents interactions that may reduce digoxin absorption. Taking the medication at the same time every day helps maintain a consistent blood level, ensuring optimal therapeutic effects.
2. A client asks a nurse about the purpose of advance directives.
- A. Indicate a form of treatment a client is willing to accept.
- B. Specify the client's preferred hospital for treatment.
- C. Determine the client's daily medication schedule.
- D. Outline the client's financial status and insurance coverage.
Correct answer: A
Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.
3. The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?
- A. If I exercise at least twice weekly for one hour, I will lower my cholesterol.
- B. I need to avoid eating proteins, including red meat.
- C. I will limit my intake of beef to 4 ounces per week.
- D. My blood level of low-density lipoproteins needs to increase.
Correct answer: C
Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.
4. 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.
5. 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.
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