HESI LPN
Fundamentals of Nursing HESI
1. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?
- A. Prolonged use does not typically cause dark concentrated urine.
- B. It is not necessary to take the medication on an empty stomach for optimal absorption.
- C. Avoid taking the medication with aluminum hydroxide to minimize GI upset.
- D. Drinking alcohol daily can cause drug-induced hepatitis.
Correct answer: D
Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.
2. What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.
3. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?
- A. “Blood pressure 160/92 mm Hg”
- B. “Start the first dose of penicillin at 1200”
- C. “Pain rating of 5 on a scale from 0 to 10”
- D. “Code status: do-not-resuscitate”
Correct answer: B
Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.
4. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client’s BP.
Correct answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
5. The nurse is caring for a client with a newly placed colostomy. Which statement by the client indicates a need for additional teaching?
- A. I will need to change the colostomy bag every day.
- B. I should avoid foods that can cause gas, such as beans and carbonated drinks.
- C. I need to empty the colostomy bag when it is one-third to one-half full.
- D. I will need to take care of the skin around the stoma to prevent irritation.
Correct answer: A
Rationale: The correct answer is A. Changing the colostomy bag every day is not necessary; it should be changed as needed, usually every 3-7 days. This statement indicates a need for additional teaching as frequent changes can irritate the skin and are not typically required. Choices B, C, and D are all correct statements regarding colostomy care. Avoiding gas-producing foods, emptying the bag when it is one-third to one-half full, and taking care of the skin around the stoma are all essential aspects of colostomy care to prevent complications and maintain skin integrity.
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