HESI LPN
Fundamentals of Nursing HESI
1. During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse’s priority?
- A. A client who received crush injuries to the chest and abdomen and is expected to die.
- B. A client who has a 4-inch laceration to the head.
- C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
- D. A client who has a fractured fibula and tibia.
Correct answer: C
Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.
2. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?
- A. Shortness of breath on exertion
- B. Weight gain of 2 pounds in a week
- C. Orthopnea
- D. Crackles in the lungs
Correct answer: D
Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.
3. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses a brush to scrub under her nails.
- C. The nurse washes for at least 30 seconds.
- D. The nurse uses alcohol-based hand rub only.
Correct answer: A
Rationale: Proper surgical hand-washing technique involves keeping the hands higher than the elbows to prevent contamination. Washing with hands held lower than the elbows can lead to potential contamination. Using a brush to scrub under the nails is not recommended as it can cause microabrasions, increasing infection risk. While washing for at least 30 seconds is a good practice for thorough hand hygiene, hand positioning is critical during surgical hand-washing. Using alcohol-based hand rub alone is insufficient for surgical hand-washing as it may not effectively remove dirt, debris, and transient microorganisms.
4. What is the rate of delivery in mL/hr if a total volume of 750 mL is infused over a period of 7 hours?
- A. 107 mL/hr.
- B. 107 mL/hr.
- C. 107 mL/hr.
- D. 107 mL/hr.
Correct answer: A
Rationale: The correct rate of delivery is 107 mL/hr. To find the rate of delivery, divide the total volume by the total time: 750 mL / 7 hours = 107 mL/hr. Choice B, C, and D are incorrect as they do not match the correct calculation based on the total volume and time provided.
5. A healthcare provider is providing range of motion to the shoulder and must perform external rotation. Which action will the provider take?
- A. Moves the patient's arm in a full circle.
- B. Moves the patient's arm across the body as far as possible.
- C. Moves the patient's arm behind the body, keeping the elbow straight.
- D. Moves the patient's arm until the thumb is upward and lateral to the head with the elbow flexed.
Correct answer: D
Rationale: The correct action for external rotation of the shoulder involves moving the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position maximizes external rotation at the shoulder joint. Choices A, moving the arm in a full circle, B, moving the arm across the body, and C, moving the arm behind the body with the elbow straight, do not describe external rotation and are incorrect. Therefore, Choice D is the correct action for performing external rotation.
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