HESI LPN
HESI Fundamentals Exam
1. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- A. Educating clients about the recommended immunization schedule for adults
- B. Teaching clients how to manage chronic illnesses
- C. Providing counseling for depression
- D. Offering support groups for cancer survivors
Correct answer: A
Rationale: The correct answer is A: Educating clients about the recommended immunization schedule for adults. This activity falls under primary prevention, which aims to prevent the onset of illness or injury. Immunizations are a proactive measure to protect individuals from developing certain diseases. Choices B, C, and D involve managing chronic illnesses, providing counseling for mental health issues, and offering support for individuals who have already experienced cancer, respectively. These activities are more aligned with secondary or tertiary prevention, focusing on managing existing conditions or preventing complications in those already affected.
2. During an admission assessment for an older adult client, what is the priority action for the nurse after gathering data and reviewing systems?
- A. Orient the client to their room.
- B. Conduct a client care conference.
- C. Review medical prescriptions.
- D. Develop a plan of care.
Correct answer: A
Rationale: The priority action for the nurse after completing the assessment and review of systems for an older adult client is to orient them to their room. This is crucial for ensuring the client's comfort and safety in the new environment. While reviewing medical prescriptions and developing a plan of care are important aspects of the admission process, they can be done after the client has been oriented to their room.
3. When caring for a client with diarrhea due to Shigella, which of the following precautions should the nurse take?
- A. Wash hands before and after contact with the client
- B. Wear a surgical mask
- C. Use a face shield
- D. Wear a gown and gloves only
Correct answer: A
Rationale: The correct precaution for Shigella infection is to wash hands thoroughly before and after contact with the client. Shigella is transmitted through the fecal-oral route, so hand hygiene is crucial in preventing its spread. Wearing a surgical mask or face shield is not necessary for Shigella as it is not primarily transmitted through respiratory droplets. While wearing a gown and gloves is important for standard precautions, the key precaution specific to Shigella is proper hand hygiene.
4. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching?
- A. I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.
- B. MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.
- C. I will protect others from exposure when I transport the client outside the room.
- D. To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.
Correct answer: C
Rationale: The correct answer is C. Protecting others from exposure when transporting a client with MRSA is crucial in preventing the spread of infection. This statement demonstrates understanding of infection control measures. Stating that MRSA is usually resistant to vancomycin (choice B) is incorrect; vancomycin is often effective against MRSA. Obtaining a specimen for culture and sensitivity after the first dose of an antimicrobial (choice A) is unnecessary and not indicated. Discontinuing antimicrobial therapy when the client is no longer febrile (choice D) is incorrect because antimicrobial therapy should be completed as prescribed to prevent the development of resistant strains.
5. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?
- A. Bag bath
- B. Sponge bath
- C. Partial bed bath
- D. Complete bed bath
Correct answer: C
Rationale: The correct answer is a partial bed bath (Choice C). A partial bed bath involves washing body parts that the patient cannot reach on their own, such as the back. It also includes providing assistance with a backrub to promote circulation and skin integrity. In this scenario, where the patient is bedridden and unable to reach all body parts, a partial bed bath is the most appropriate as it focuses on areas the patient cannot clean themselves. Choices A, B, and D are incorrect because a bag bath involves using premoistened disposable cloths for bathing, a sponge bath involves using a basin of water and a sponge for cleansing, and a complete bed bath involves washing the entire body, including areas the patient can reach, which are not necessary in this case.
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