HESI LPN
Fundamentals HESI
1. When caring for a client at the end of life, which statement by the client’s partner reflects effective coping?
- A. I am relying on support from our family during this time.
- B. I am feeling overwhelmed but don’t want to talk about it.
- C. I am managing everything on my own without help.
- D. I prefer to stay alone with my partner.
Correct answer: A
Rationale: The correct answer is A: 'I am relying on support from our family during this time.' When a client is at the end of life, relying on support from family can be an effective coping mechanism. It allows the partner to share the emotional burden, seek comfort, and prevent feelings of isolation. Choice B reflects a reluctance to express feelings, which can hinder coping mechanisms by internalizing stress. Choice C suggests handling everything alone, which can lead to burnout and emotional strain due to the overwhelming responsibilities. Choice D, preferring to stay alone with the partner, may limit access to external support that could provide additional emotional and practical assistance during this challenging time, making it a less effective coping strategy.
2. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?
- A. ''I am going to listen to your abdomen.''
- B. ''You need to wait until the surgeon evaluates your condition.''
- C. ''You can have clear liquids, but let me check with the surgeon first.''
- D. ''It is best to start with small sips of clear liquids and observe how you feel.''
Correct answer: A
Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client’s gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.
3. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
- A. Roof of mouth, gums, and inside cheeks
- B. Chewing and inner tooth surfaces
- C. Outer tooth surfaces
- D. Tongue
Correct answer: C
Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.
4. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?
- A. Folic acid should be taken before and after conception.
- B. Multivitamin supplements are recommended during pregnancy.
- C. A well-balanced diet promotes normal fetal development.
- D. Increased dietary iron improves the health of mother and fetus.
Correct answer: A
Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.
5. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
- A. Evaluate electrolytes
- B. Restrict fluid intake
- C. Administer diuretics
- D. Monitor vital signs
Correct answer: A
Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.
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