HESI LPN
Fundamentals HESI
1. A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?
- A. Gelatin
- B. Whole milk
- C. Cream soups
- D. Orange juice
Correct answer: A
Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.
2. A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
- A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
- B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
- C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
- D. Mention, 'Many people with diabetes manage well with insulin injections.'
Correct answer: A
Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.
3. The healthcare provider is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...
- A. Notify the surgeon of the client’s concern
- B. Have the client sign a new surgical permit
- C. Add the client’s concern to the permit
- D. Inform the surgeon about the client’s concern
Correct answer: D
Rationale: In this scenario, the best course of action is to inform the surgeon about the client's concern. This action ensures that the surgeon is aware of the client's specific request or concern related to the procedure. By directly involving the surgeon, the client's preferences or needs can be addressed effectively, potentially avoiding any misunderstanding or dissatisfaction. Choice A has been corrected to 'Notify the surgeon of the client’s concern' as the operating room staff may not have the authority to make changes to the permit. Having the client sign a new surgical permit (Choice B) may not be necessary if the concern can be addressed by informing the surgeon, making Choice B less efficient. Adding the client’s concern to the permit (Choice C) without consulting the surgeon may not align with the standard procedure and could lead to confusion or legal issues if the surgeon is not aware of the client’s specific requests.
4. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?
- A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
- B. Emptying the device every 4 hours.
- C. Replacing the device every 24 hours.
- D. Keeping the device above the level of the surgical site.
Correct answer: A
Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.
5. Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?
- A. Delegates assessment of lung sounds to nursing assistive personnel
- B. Becomes solely responsible for modifying activities of daily living
- C. Consults physical therapy for strengthening exercises in the extremities
- D. Involves respiratory therapy for altered breathing from severe anxiety levels
Correct answer: C
Rationale: Consulting physical therapy for strengthening exercises in the extremities demonstrates a team approach in caring for a patient with mobility issues. Involving other healthcare professionals like physical therapists ensures a comprehensive and specialized approach to address the patient's mobility needs. This collaborative approach benefits the patient by providing specialized interventions. Choices A, B, and D do not exemplify a collaborative team approach. Delegating assessment tasks to nursing assistive personnel (Choice A) may not address the mobility issue directly. Becoming solely responsible for modifying activities of daily living (Choice B) limits the scope of interventions. Involving respiratory therapy for anxiety-related breathing issues (Choice D) addresses a different aspect of care and does not directly target mobility concerns.
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