HESI LPN
HESI Fundamentals 2023 Quizlet
1. A client has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
- A. Discard the first voiding.
- B. Keep the urine in a single container on ice.
- C. Include the last voiding in the collection.
- D. Instruct the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.
Correct answer: A
Rationale: The correct action for the nurse to take when a client has a prescription for a 24-hour urine collection is to discard the first voiding. This initial voiding is typically not collected to allow for the accurate start of the 24-hour collection period. All subsequent urine voided within the specified time frame is then collected. Including the last voiding in the collection is important to ensure that the full 24-hour period is covered. It is essential to keep the urine cool by storing it in a single container on ice to prevent degradation of components. Instructing the client to stop midstream and finish urinating into the specimen container is not required for a 24-hour urine collection and is an unnecessary step.
2. While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?
- A. Ask the student, 'What did you forget to do?'
- B. Stop and explain why aspiration is needed.
- C. Quietly state, 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'
Correct answer: D
Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.
3. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include?
- A. “Use full-length side rails on the client’s bed.”
- B. “Check on the client frequently while they are in the restroom.”
- C. “Encourage physical activity throughout the day to expend energy.”
- D. “Remove clocks from the client’s room.”
Correct answer: C
Rationale: Encouraging physical activity is an effective non-restraint intervention for managing confused clients. It helps reduce agitation, promotes circulation, and may decrease the need for restraints. Choice A is incorrect as using full-length side rails can potentially restrict a client's movement, which is counterproductive to avoiding restraints. Choice B, while emphasizing monitoring, does not directly address alternatives to restraint use. Choice D is also incorrect as removing clocks from the client's room does not directly address managing confusion and reducing the need for restraints.
4. Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?
- A. Oil Retention
- B. Saline
- C. Soapy Water
- D. Hypertonic
Correct answer: A
Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.
5. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
- D. Before changing assignments, determine which staff members have fitted particulate filter masks
Correct answer: D
Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.
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