HESI LPN
Fundamentals HESI
1. A client asks a nurse about the purpose of advance directives.
- A. Indicate a form of treatment a client is willing to accept.
- B. Specify the client's preferred hospital for treatment.
- C. Determine the client's daily medication schedule.
- D. Outline the client's financial status and insurance coverage.
Correct answer: A
Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.
2. A client who has recently started using a behind-the-ear hearing aid is being cared for by a nurse. Which of the following statements should the nurse identify as an indication that the client understands the use of assistive devices?
- A. “I will be sure to remove my hearing aid before taking a shower.”
- B. “I will keep my hearing aid in at all times, even when sleeping.”
- C. “I will clean my hearing aid with alcohol.”
- D. “I will turn off my hearing aid when not in use.”
Correct answer: A
Rationale: The correct answer is A. It is crucial for the client to remove the hearing aid before showering to prevent damage from moisture. Choice B is incorrect as wearing the hearing aid all the time, including during sleep, is not recommended and can cause discomfort or harm. Choice C is incorrect as alcohol can damage hearing aids; they should be cleaned with a solution recommended by the manufacturer to prevent harm. Choice D is incorrect because hearing aids should not be turned off when not in use; instead, they should be stored properly following the manufacturer's instructions to maintain functionality and battery life.
3. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
- A. “I will determine the most important client problems that we should address.”
- B. “I will review the past medical history on the client’s record to gather more information.”
- C. “I will carry out the new prescriptions from the provider.”
- D. “I will ask the client if their nausea has resolved.”
Correct answer: A
Rationale: In the nursing process, the planning step involves determining priorities and goals based on the identified problems. Choice A is correct as it reflects the nurse's role in identifying the most important client problems to address, which aligns with the planning phase. Choices B, C, and D are incorrect. Choice B involves data collection, which is a part of the assessment phase, not planning. Choice C pertains to the implementation of care, which occurs after the planning phase. Choice D involves evaluation of a specific intervention, not planning.
4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include?
- A. Writing a prescription for morphine sulfate as needed for pain
- B. Inserting a nasogastric (NG) tube to relieve gastric distention
- C. Showing a client how to use progressive muscle relaxation
- D. Performing a daily bath after the evening meal
Correct answer: C
Rationale: The correct answer is C. Showing a client how to use progressive muscle relaxation is an intervention that does not require a provider's prescription. This falls within the nurse's scope of practice and can be implemented to promote relaxation and reduce stress for the client. Choices A and B involve tasks that require a provider's prescription and specialized training. Writing a prescription for morphine sulfate and inserting an NG tube should only be done by authorized healthcare providers. Choice D, performing a daily bath, while within the nurse's scope, does not specifically address interventions that do not require a provider's prescription.
5. A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client, “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse’s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?
- A. Basic
- B. Commitment
- C. Complex
- D. Integrity
Correct answer: C
Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.
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