HESI LPN
Fundamentals HESI
1. When administering an otic medication to an older adult client, which action should the nurse take to ensure that the medication reaches the inner ear?
- A. Press gently on the tragus of the client's ear
- B. Pack a small piece of cotton deep into the client's ear canal
- C. Move the client's auricle down and back toward their head
- D. Tilt the client's head backward for 5 minutes
Correct answer: A
Rationale: The correct action to ensure that otic medication reaches the inner ear is to press gently on the tragus. The tragus is a small cartilaginous projection in front of the ear canal. Pressing on it helps to straighten the ear canal, allowing the medication to reach the inner ear. Packing cotton or moving the auricle can obstruct the ear canal and prevent proper medication delivery. Tilting the client's head backward is not necessary and may not facilitate the medication reaching the inner ear as effectively as pressing on the tragus.
2. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?
- A. Headache
- B. Blurred vision
- C. Dizziness
- D. Chest pain
Correct answer: D
Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.
3. A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Tuberculosis
Correct answer: D
Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.
4. A client with chronic obstructive pulmonary disease (COPD) is being discharged with home oxygen therapy. Which statement by the client indicates a need for further teaching?
- A. I will keep my oxygen tank upright at all times.
- B. I will not use petroleum jelly to keep my nose from drying out.
- C. I will not smoke or allow others to smoke around me.
- D. I will call my doctor if I have difficulty breathing.
Correct answer: B
Rationale: The correct answer is B. Petroleum jelly is flammable and should not be used with oxygen therapy due to the risk of fire. The client should avoid using petroleum-based products around oxygen equipment. Choices A, C, and D are all appropriate statements for a client with COPD receiving home oxygen therapy. Keeping the oxygen tank upright ensures proper oxygen flow, avoiding smoking or exposure to smoke helps prevent respiratory aggravation, and knowing to seek medical help promptly for breathing difficulties is essential for managing COPD effectively.
5. When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?
- A. A word whispered by the nurse 30cm from the ear
- B. A number traced on the palm of the hand
- C. The vibration of a tuning fork placed on the foot
- D. A familiar object placed in the hand
Correct answer: B
Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.
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