HESI LPN
Fundamentals HESI
1. A client asks a nurse about the purpose of advance directives.
- A. Indicate a form of treatment a client is willing to accept.
- B. Specify the client's preferred hospital for treatment.
- C. Determine the client's daily medication schedule.
- D. Outline the client's financial status and insurance coverage.
Correct answer: A
Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.
2. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?
- A. “Blood pressure 160/92 mm Hg”
- B. “Start the first dose of penicillin at 1200”
- C. “Pain rating of 5 on a scale from 0 to 10”
- D. “Code status: do-not-resuscitate”
Correct answer: B
Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.
3. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?
- A. Chamomile
- B. Ginseng
- C. Ginger
- D. Echinacea
Correct answer: A
Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.
4. 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.
5. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?
- A. Apply a condom catheter.
- B. Apply a skin protectant.
- C. Encourage increased fluid intake.
- D. Assess for bladder distention.
Correct answer: D
Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.
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