HESI LPN
HESI Fundamentals Test Bank
1. A client scheduled for abdominal surgery reports being worried. Which of the following actions should the nurse take?
- A. Offer information on a relaxation technique and ask if the client is interested in trying it.
- B. Request a social worker to see the client to discuss meditation.
- C. Attempt to use biofeedback techniques with the client.
- D. Tell the client many people feel the same way before surgery and to think of something else.
Correct answer: A
Rationale: Offering relaxation techniques addresses the client's immediate concern by providing a proactive approach to managing anxiety. It shows empathy and offers a practical solution. Requesting a social worker for meditation (Choice B) may not be the most direct response to the client's immediate worry. Attempting biofeedback (Choice C) may not be suitable without the client's interest or consent. Telling the client to think of something else (Choice D) dismisses the client's feelings and does not provide constructive support.
2. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
- A. Establish goals that are measurable and realistic.
- B. Set goals that are a little beyond the capabilities of the patient.
- C. Use the nurse's own judgment and not be swayed by family desires.
- D. Explain that without taking alignment risks, there can be no progress.
Correct answer: A
Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.
3. A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Nonmaleficence
Correct answer: D
Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.
4. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?
- A. Dietitian consult
- B. Speech therapy referral
- C. Oral suction at the bedside
- D. Clear liquids
Correct answer: D
Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids or pureed foods. Therefore, the nurse should clarify the prescription for clear liquids to prevent potential harm to the client. Choices A, B, and C are appropriate interventions for a client with dysphagia following a stroke. A dietitian consult can help modify the client's diet for safe swallowing, speech therapy can assist in improving swallowing function, and oral suction at the bedside helps maintain airway patency and prevents aspiration.
5. 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.
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