HESI LPN
Fundamentals HESI
1. 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.
2. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
- A. Defer the bath until evening and pass on the information to the next shift.
- B. Tell the patient that daily morning baths are part of the 'normal' routine.
- C. Explain the importance of maintaining morning hygiene practices.
- D. Cancel hygiene for the day and attempt again in the morning.
Correct answer: A
Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.
3. During an abdominal assessment for an adult client, what is the correct sequence of steps?
- A. Inspect, Auscultate, Percuss, Palpate
- B. Palpate, Percuss, Inspect, Auscultate
- C. Auscultate, Inspect, Percuss, Palpate
- D. Percuss, Palpate, Inspect, Auscultate
Correct answer: A
Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.
4. 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.
5. To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
- A. Every 4 to 8 hours
- B. Every 12 to 24 hours
- C. Every 24 to 48 hours
- D. Every 72 to 96 hours
Correct answer: D
Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.
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