HESI LPN
HESI Fundamentals Study Guide
1. A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?
- A. Activate the emergency fire alarm
- B. Extinguish the fire
- C. Evacuate the client
- D. Confine the fire
Correct answer: C
Rationale: The correct action for the nurse to take next, after confirming the fire, is to evacuate the client. In a fire situation, following the RACE mnemonic, the priority is to rescue or evacuate clients to ensure their safety. Activating the emergency fire alarm (Choice A) is important to alert others and the fire department, but evacuating the client takes precedence. Extinguishing the fire (Choice B) may put the nurse and client at risk and is best left to trained personnel. Confining the fire (Choice D) is not the nurse's responsibility; the focus should be on ensuring the client's safety by evacuating them.
2. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?
- A. Decreased subcutaneous fat
- B. Muscle atrophy
- C. Pressure injury
- D. Fecal impaction
Correct answer: C
Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.
3. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
- A. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
- B. The nurse avoids discussing the client's diagnosis to prevent emotional distress.
- C. The nurse provides a vague answer about the client's condition.
- D. The nurse promises to provide information only if it is requested by the client.
Correct answer: A
Rationale: Veracity involves telling the truth, a fundamental ethical principle in healthcare. In this scenario, the nurse demonstrates veracity by responding honestly when the client directly asks about her cancer diagnosis. Choice B is incorrect as avoiding discussing the diagnosis to prevent emotional distress does not align with veracity and transparency. Choice C is incorrect as providing a vague answer does not uphold the principle of truthfulness. Choice D is incorrect because promising to provide information only upon client request does not address the immediate question about the cancer diagnosis and lacks transparency.
4. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
- A. The client reports severe pain
- B. The client asks for a demonstration
- C. The client inquires about potential complications
- D. The client agrees to the procedure
Correct answer: A
Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.
5. The nurse is preparing to administer a subcutaneous injection of insulin to a client with diabetes. What is the best site for the nurse to select for this injection?
- A. Ventrogluteal site
- B. Dorsogluteal site
- C. Deltoid site
- D. Abdomen
Correct answer: D
Rationale: The correct answer is 'D: Abdomen.' The abdomen is the best site for insulin injections as it provides a larger area with consistent absorption rates due to the high vascularity of the area. The subcutaneous tissue in the abdomen allows for a more predictable and consistent absorption of insulin compared to other sites. Ventrogluteal and dorsogluteal sites are not commonly used for insulin injections due to the risk of hitting the sciatic nerve or causing tissue damage. The deltoid site is more commonly used for intramuscular injections rather than subcutaneous injections like insulin.
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