HESI LPN
Fundamentals of Nursing HESI
1. A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?
- A. Assist the client with a partial bed bath
- B. Measure the client’s blood pressure after the nurse administers antihypertensive medications
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct answer: A
Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.
2. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
- A. A client who has asthma.
- B. A client who has diabetes.
- C. A client who has hypertension.
- D. A client who has a history of depression.
Correct answer: A
Rationale: The correct answer is A: a client who has asthma. Essential oils have the potential to trigger asthma symptoms due to their strong scents and chemical components. Consulting with the healthcare provider is crucial before using aromatherapy with essential oils to ensure the safety and well-being of the client with asthma. Choices B, C, and D do not pose immediate risks with aromatherapy use, making them less of a priority for consultation compared to asthma. Clients with diabetes, hypertension, or depression do not have the same immediate risks associated with the use of aromatherapy as clients with asthma. However, it is still advisable for the nurse to be aware of any potential interactions or contraindications with these conditions and consult with the provider if needed.
3. A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?
- A. Hypoglycemia
- B. Hyperglycemia
- C. Hypertension
- D. Hyperkalemia
Correct answer: B
Rationale: Hyperglycemia is the correct complication to monitor for in a client receiving total parenteral nutrition (TPN) due to the high glucose content of the solution. TPN solutions are rich in glucose, so monitoring blood glucose levels is crucial to prevent hyperglycemia. Hypoglycemia (Choice A) is less common with TPN due to the high glucose content, making hyperglycemia a more significant concern. Hypertension (Choice C) and hyperkalemia (Choice D) are not typically associated with TPN administration, making them incorrect choices in this scenario.
4. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?
- A. I will avoid eating foods high in vitamin K.
- B. I will take my medication at the same time every day.
- C. I will use a soft toothbrush to prevent gum bleeding.
- D. I can take aspirin if I have a headache.
Correct answer: D
Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.
5. A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?
- A. Ptosis
- B. Hematuria
- C. Urticaria
- D. Nausea
Correct answer: C
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.
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