HESI LPN
Fundamentals HESI
1. The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?
- A. Encourage the client to perform active range-of-motion exercises.
- B. Use pillows to keep the client's extremities in a functional position.
- C. Place the client in a prone position for 30 minutes each day.
- D. Perform passive range-of-motion exercises on the affected side.
Correct answer: B
Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.
2. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
- A. “The client’s age is not a factor in the measurement.”
- B. “The scale measures six elements.”
- C. “A lower score indicates a higher risk of pressure ulcers.”
- D. “Each element is scored on a range from 1 to 4 points.”
Correct answer: B
Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.
3. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)
- A. “The temperature around the IV site is cooler.”
- B. “The rate of the infusion increases.”
- C. “The skin at the IV site is red.”
- D. “The IV dressing is damp.”
Correct answer: A
Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.
4. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct answer: D
Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.
5. A healthcare provider is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the healthcare provider plan to take?
- A. Place the client in Trendelenburg's position.
- B. Position the client in an upright sitting position.
- C. Administer bronchodilators after the procedure.
- D. Perform chest percussion and vibration while the client is lying flat.
Correct answer: A
Rationale: Placing the client in Trendelenburg's position is the appropriate action when providing chest physiotherapy for a client with left lower lobe atelectasis. This position helps mobilize secretions from the lower lobes of the lungs, aiding in their clearance. Trendelenburg's position promotes drainage from the affected area. Positioning the client in an upright sitting position (Choice B) would not facilitate the drainage of secretions from the affected lobe. Administering bronchodilators after the procedure (Choice C) is not directly related to chest physiotherapy and the treatment of atelectasis. Performing chest percussion and vibration while the client is lying flat (Choice D) may not effectively target the lower lobes where the atelectasis is located.
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