HESI LPN
Fundamentals of Nursing HESI
1. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
- A. A client who has asthma.
- B. A client who has diabetes.
- C. A client who has hypertension.
- D. A client who has a history of depression.
Correct answer: A
Rationale: The correct answer is A: a client who has asthma. Essential oils have the potential to trigger asthma symptoms due to their strong scents and chemical components. Consulting with the healthcare provider is crucial before using aromatherapy with essential oils to ensure the safety and well-being of the client with asthma. Choices B, C, and D do not pose immediate risks with aromatherapy use, making them less of a priority for consultation compared to asthma. Clients with diabetes, hypertension, or depression do not have the same immediate risks associated with the use of aromatherapy as clients with asthma. However, it is still advisable for the nurse to be aware of any potential interactions or contraindications with these conditions and consult with the provider if needed.
2. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?
- A. 'All of this equipment can be frightening.'
- B. 'The equipment is necessary to monitor your condition.'
- C. 'You should try to ignore the equipment.'
- D. 'Try to relax; the equipment is not harmful.'
Correct answer: A
Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.
3. When using an open irrigation technique for a client's catheter, what action should the nurse take?
- A. Subtract the amount of irrigant used from the client's urine output.
- B. Add the amount of irrigant used to the urine output measurement.
- C. Measure the amount of irrigant used separately from the urine output.
- D. Document the total amount of fluid used for irrigation only.
Correct answer: A
Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.
4. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?
- A. Ensure the client wears a mask when outside the room if there is construction nearby.
- B. Place the client in a private room with positive pressure airflow.
- C. Restrict all visitors from seeing the client.
- D. Provide a HEPA filter in the client's room.
Correct answer: A
Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.
5. A client expresses that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make?
- A. “I believe in this case you should make an exception and accept the blood transfusion.”
- B. “I know your family would approve of your decision to have a blood transfusion.”
- C. “Why does your religion mandate that you cannot receive any blood transfusions?”
- D. “Let’s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.”
Correct answer: D
Rationale: The correct response is to involve the client's religious and spiritual leaders in the discussion to find a solution that respects both the client's values and medical needs. Option A is incorrect as it dismisses the client's beliefs. Option B assumes the family's opinion over the client's. Option C is inappropriate as it questions the client's religious beliefs rather than addressing the concern respectfully.
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