HESI LPN
HESI Fundamentals 2023 Test Bank
1. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
- A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.
- B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.
- C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
- D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
Correct answer: C
Rationale: In this situation, it's essential to acknowledge and respect the client's feelings and choices. Choice C is the most appropriate response as it validates the client's decision not to discuss the surgery while offering support and understanding. Giving the client space and letting them know you will be available when they are ready shows empathy and fosters trust. Choices A and B do not respect the client's autonomy and may come across as dismissive or pressuring. Choice D assumes the client needs advice from someone who has had a similar experience without considering the client's current emotional state and preferences.
2. What instruction should the nurse provide for a UAP caring for a client with MRSA who has a prescription for contact precautions?
- A. Allow visitors with precautions in place
- B. Wear sterile gloves when handling the client's body fluid
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the room. Wearing a gown and gloves is necessary to prevent the transmission of MRSA. Choice A is incorrect because visitors may be allowed with proper precautions in place. Choice B is incorrect as it assumes the client has body fluid precautions, which is not specified. Choice C is incorrect as it does not address the UAP's protective measures but rather focuses on the client wearing a mask.
3. A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?
- A. 4-5 times per hour
- B. 2-3 times per hour
- C. 6-7 times per hour
- D. 8-10 times per hour
Correct answer: A
Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.
4. The healthcare provider is assessing a client who has a chest tube in place following a pneumothorax. Which finding should be reported to the healthcare provider immediately?
- A. Bubbling in the water seal chamber
- B. Drainage greater than 70 ml/hour
- C. Tidaling in the water seal chamber
- D. Absence of breath sounds on the affected side
Correct answer: D
Rationale: The absence of breath sounds on the affected side is a critical finding that may indicate a tension pneumothorax, a life-threatening condition requiring immediate intervention. This situation can lead to a shift of the mediastinum and impaired ventilation. Bubbling in the water seal chamber is an expected finding in a chest tube drainage system and indicates proper functioning. Drainage greater than 70 ml/hour is a concern but does not require immediate reporting unless it continues at a high rate or is associated with other symptoms. Tidaling in the water seal chamber is a normal fluctuation and indicates the chest tube system is patent and functioning correctly.
5. The nurse is caring for a client with a central venous catheter. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter dressing every 72 hours.
- B. Flush the catheter with heparin solution daily.
- C. Ensure the catheter is clamped when not in use.
- D. Maintain sterile technique when handling the catheter.
Correct answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. Changing the catheter dressing every 72 hours, while important for overall catheter care, does not directly address infection prevention. Flushing the catheter with heparin solution daily is essential for maintaining patency but does not primarily prevent infections. Ensuring the catheter is clamped when not in use is important for preventing air embolism but is not the most critical action to prevent infection. The most effective way to prevent infections is by strictly adhering to sterile techniques during catheter handling, which minimizes the risk of introducing pathogens into the catheter site.
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