HESI LPN
Fundamentals HESI
1. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action
- A. May result in charges of unlawful seclusion and restraint
- B. Leaves the nurse vulnerable to charges of assault and battery
- C. Was appropriate given the client's history of violence
- D. Was necessary to maintain the therapeutic milieu of the unit
Correct answer: A
Rationale: Seclusion should only be used when necessary and with proper documentation; otherwise, it may be considered unlawful. Placing a client in seclusion without a clear indication or proper documentation could lead to legal ramifications, making choice A the correct answer. Choice B is incorrect because assault and battery do not apply in this scenario. Choice C is incorrect as there is no mention of the client posing an imminent threat due to a history of violence. Choice D is incorrect as seclusion should not be used solely to maintain the therapeutic milieu but rather for the safety of the client and others.
2. 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.
3. A client with Parkinson's disease is being discharged. Which statement by the client indicates a need for further teaching?
- A. I will take my medication at the same time every day.
- B. I will increase my fiber intake to prevent constipation.
- C. I will perform range of motion exercises to maintain mobility.
- D. I will stop taking my medication if I feel better.
Correct answer: D
Rationale: The correct answer is D. Patients with Parkinson's disease should not stop taking their medication if they feel better, as doing so can worsen symptoms. It is crucial for patients to continue their prescribed medication regimen as directed by their healthcare provider. Choices A, B, and C are all appropriate actions that promote the well-being of a client with Parkinson's disease. Choice A emphasizes medication adherence, which is vital for symptom management. Choice B addresses a common issue in Parkinson's patients and shows an understanding of the importance of dietary management. Choice C highlights the significance of physical activity in maintaining mobility, which is essential for overall quality of life in Parkinson's disease.
4. After a client's death in a long-term care facility, identify the correct sequence of steps for the nurse to perform.
- A. 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body
- B. 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body
- C.
- D.
Correct answer: B
Rationale: The correct sequence of steps for the nurse in a long-term care facility after a client's death is as follows: First, obtain the pronouncement of death from the provider. Second, remove tubes and indwelling lines before proceeding to wash the client's body. Third, ask the client's family members if they would like to view the body. Finally, place a name tag on the body. This order ensures that the necessary procedures are followed with respect and consideration for the deceased client and their family. Choice B is correct. Choices A, C, and D are incorrect as they do not follow the appropriate sequence of actions required in this situation.
5. During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?
- A. Potassium 5.5 mEq/L
- B. Irritation of nasal mucosa
- C. Sodium 144 mEq/L
- D. Loose stools
Correct answer: B
Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99