HESI LPN
HESI Fundamentals Exam
1. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct answer: B
Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.
2. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?
- A. There are times I should use soap and water rather than alcohol-based hand rub to clean my hands.
- B. I can use alcohol-based hand rub after using the restroom.
- C. Soap and water are only necessary if my hands are visibly dirty.
- D. Hand rub is always sufficient, regardless of the situation.
Correct answer: C
Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.
3. The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?
- A. I will reduce my salt intake.
- B. I will exercise for 30 minutes most days of the week.
- C. I will drink alcohol only on the weekends.
- D. I will monitor my blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Clients with hypertension should ideally avoid or limit alcohol intake rather than just restricting it to weekends. Excessive alcohol consumption can raise blood pressure and interfere with the effectiveness of hypertension management. Choices A, B, and D are all positive statements that align with managing hypertension: reducing salt intake, regular exercise, and monitoring blood pressure are all beneficial lifestyle changes for individuals with hypertension. Therefore, the statement about drinking alcohol only on weekends requires further teaching to emphasize the importance of reducing alcohol consumption for better blood pressure control.
4. A client who has a new prescription for warfarin (Coumadin) is receiving discharge teaching from a nurse. Which of the following statements indicates that the client understands the teaching?
- A. I will take my warfarin at the same time every day.
- B. I should use a soft-bristled toothbrush while taking this medication.
- C. I should take my warfarin at bedtime.
- D. I should avoid eating foods high in vitamin K while taking this medication.
Correct answer: A
Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.
5. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct answer: D
Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.
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