HESI LPN
Fundamentals HESI
1. 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.
2. 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.
3. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?
- A. Capillary refill less than 3 seconds
- B. 1+ pitting edema in both feet
- C. Pale nail beds in both hands
- D. Thick skin on the soles of the feet
Correct answer: A
Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.
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 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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