HESI LPN
Fundamentals of Nursing HESI
1. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
- A. Obtaining cotton balls for the tracheostomy care
- B. Using a sterile water bottle
- C. Checking the suction equipment
- D. Wearing a sterile gown
Correct answer: A
Rationale: The correct answer is A. Obtaining cotton balls for tracheostomy care is not recommended due to the risk of fiber contamination. Sterile gauze should be used instead. Choice B, using a sterile water bottle, is a correct and appropriate action for tracheostomy care to maintain cleanliness. Choice C, checking the suction equipment, is also a necessary step to ensure it is functioning properly for the procedure. Choice D, wearing a sterile gown, is a standard precaution to maintain a sterile environment during tracheostomy care.
2. A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
- A. the medication
- B. the route
- C. the dose
- D. the frequency
Correct answer: C
Rationale: The healthcare professional should question the dose indicated in the prescription. In this case, '0.25' is incomplete without a unit of measurement, such as mg (milligrams). Without a specified unit, the dose lacks the necessary information for accurate administration. Choices A, B, and D are not incorrect components to question in medication prescriptions; however, in this scenario, the incompleteness of the dose is the most critical concern that needs clarification to ensure safe and effective medication administration.
3. When initiating cardiopulmonary resuscitation (CPR), what assessment finding must the healthcare provider confirm before beginning chest compressions?
- A. Absence of a pulse
- B. Presence of a pulse
- C. Respiratory rate
- D. Blood pressure
Correct answer: A
Rationale: The correct answer is A: Absence of a pulse. Prior to initiating chest compressions during CPR, it is essential to confirm the absence of a pulse. Chest compressions are indicated when there is no detectable pulse as it signifies cardiac arrest. Checking for a pulse is a critical step to ensure that CPR is performed on individuals who truly require it. Choices B, C, and D are incorrect because focusing on the presence of a pulse, respiratory rate, or blood pressure before starting chest compressions can delay life-saving interventions in a person experiencing cardiac arrest.
4. A client with diabetes mellitus is being taught by a nurse how to perform a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching?
- A. Don sterile gloves after cleansing the site
- B. Puncture the site after cleansing and before the antiseptic dries
- C. Gently wipe the puncture site until a large droplet of blood forms
- D. Hold the finger below the heart level to puncture
Correct answer: B
Rationale: The correct instruction is to puncture the site after cleansing and before the antiseptic dries. This sequence helps ensure proper blood collection without introducing contaminants. Choice A is incorrect because wearing sterile gloves is not necessary for capillary blood glucose testing. Choice C is incorrect as wiping the puncture site can introduce contaminants and alter the blood sample. Choice D is incorrect as holding the finger below the heart level is not required for a capillary blood glucose test.
5. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?
- A. Avoid taping electrical cords to the floor.
- B. Clean electrical equipment before disconnection.
- C. Cover exposed wires with tape before use.
- D. Disconnect electrical equipment by grasping the plug.
Correct answer: A
Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.
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