HESI LPN
Fundamentals of Nursing HESI
1. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
- A. Obtaining cotton balls for the tracheostomy care
- B. Using a sterile water bottle
- C. Checking the suction equipment
- D. Wearing a sterile gown
Correct answer: A
Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.
2. Which of the following manifestations confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct answer: D
Rationale: The correct answer is D. Whitish oval specks sticking to the hair shaft are nits, which are a definitive sign of pediculosis capitis (head lice). A: Scratching the head more than usual is a common symptom but not confirmatory of head lice infestation. B: Flakes evident on a student's shoulders may indicate dandruff or dry scalp, not necessarily head lice. C: Oval pattern occipital hair loss is not a typical manifestation of pediculosis capitis.
3. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct answer: B
Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.
4. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?
- A. 0.75 mL
- B. 1 mL
- C. 0.8 mL
- D. 1.2 mL
Correct answer: C
Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.
5. A client recovering from lung cancer is advised to resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
- A. Washing dishes
- B. Mowing the lawn
- C. Carrying heavy groceries
- D. Gardening
Correct answer: A
Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.
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