HESI LPN
Fundamentals of Nursing HESI
1. What immediate action should a healthcare worker take after being stuck in the hand by an exposed needle?
- A. Look up the policy on needle sticks
- B. Contact employee health services
- C. Immediately wash the hands thoroughly with soap and water
- D. Notify the supervisor and risk management
Correct answer: C
Rationale: The correct immediate action for a healthcare worker who has been stuck by an exposed needle is to wash the hands thoroughly with soap and water to reduce the risk of infection. This helps to remove any potential pathogens introduced by the needle stick. Looking up the policy on needle sticks (Choice A) is important but not the immediate action required. Contacting employee health services (Choice B) and notifying the supervisor and risk management (Choice D) are crucial steps to take, but they should follow the initial step of washing the hands to mitigate the risk of infection.
2. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?
- A. Elevate the head of the bed to 30-45 degrees.
- B. Check residual volumes every 4 hours.
- C. Verify tube placement every shift.
- D. Flush the tube with water every 4 hours.
Correct answer: A
Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.
3. When evaluating care of an immobilized patient, which action will the nurse take?
- A. Focus on whether the interdisciplinary team is satisfied with the care.
- B. Compare the patient's actual outcomes with the outcomes in the care plan.
- C. Involve primarily the patient's family and health care team to determine goal achievement.
- D. Use objective data solely in determining whether interventions have been successful.
Correct answer: B
Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.
4. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem?
- A. Chest pain
- B. Pallor
- C. Inspiratory crackles
- D. Heart murmur
Correct answer: C
Rationale: Inspiratory crackles are a common finding in patients with congestive heart failure due to the accumulation of fluid in the lungs, leading to crackling sounds during inspiration. Chest pain (Choice A) is more commonly associated with conditions like angina or myocardial infarction and is not a typical symptom of congestive heart failure. Pallor (Choice B) is a general symptom of various conditions and not specific to congestive heart failure. While a heart murmur (Choice D) may be heard in some cases of congestive heart failure, it is not as consistent as inspiratory crackles in indicating the condition.
5. When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?
- A. Repeat each joint motion five times during each session.
- B. Perform the exercises quickly to save time.
- C. Focus only on the most affected joints.
- D. Assess the client's range of motion before starting.
Correct answer: A
Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.
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