HESI LPN
HESI Fundamentals Test Bank
1. Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?
- A. That indicates you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are dilating and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct answer: D
Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.
2. When a nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client, the next action by the nurse should be to
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct answer: A
Rationale: When a nurse experiences reluctance to interact with a manipulative client, it is essential to address these feelings constructively. Discussing the feeling of reluctance with an objective peer or supervisor allows the nurse to gain perspective, reflect on the situation, and develop appropriate strategies for patient care. This action promotes self-awareness, professional growth, and ensures that patient care is not compromised. Option B is incorrect because avoiding the client may not address the underlying issues and can impact the therapeutic relationship. Option C is inappropriate as confronting the client may escalate the situation and hinder effective communication. Option D is not the immediate action needed in this scenario, as it focuses on behavior modification rather than addressing the nurse's feelings of reluctance.
3. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
- A. "I'm having mild pain."
- B. "The pain is like a dull ache in my stomach."
- C. "I notice that the pain gets worse after I eat."
- D. "The pain makes me feel nauseous."
Correct answer: B
Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.
4. While changing the linen on the client's bed, what should the nurse do?
- A. Hold the linen away from their body and clothing.
- B. Fold the linen neatly before placing it in the laundry.
- C. Wear clean gloves while handling the linen.
- D. Place the linen directly on the floor until the new linen is in place.
Correct answer: A
Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.
5. A client who is non-ambulatory 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. Evacuate the client
- B. Attempt to extinguish the fire
- C. Call the fire department
- D. Close the door to contain the fire
Correct answer: A
Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.
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