HESI LPN
Fundamentals HESI
1. A client is experiencing a severe sore throat, pain when swallowing, and swollen lymph nodes. Which of the following stages of infection is the client likely in?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct answer: D
Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.
2. A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
- A. Clean around the stoma with povidone-iodine.
- B. Maintain sterile technique when performing tracheostomy care.
- C. Use clean technique when suctioning the tracheostomy.
- D. Change tracheostomy ties weekly.
Correct answer: B
Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.
3. A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?
- A. Schedule a support session for the client.
- B. Explain the techniques of esophageal speech.
- C. Review the use of artificial larynx with the client.
- D. Determine the client's reading ability.
Correct answer: B
Rationale: The priority intervention for a client scheduled for a total laryngectomy is to explain the techniques of esophageal speech. This is crucial for the client's post-surgery communication. Option A, scheduling a support session, is important but not the priority as ensuring the client can communicate effectively comes first. Option C, reviewing the use of artificial larynx, is relevant but not the priority compared to teaching esophageal speech. Option D, determining the client's reading ability, is not as critical as ensuring the client learns a primary method of communication following the laryngectomy.
4. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
- A. "I'm having mild pain."
- B. "The pain is like a dull ache in my stomach."
- C. "I notice that the pain gets worse after I eat."
- D. "The pain makes me feel nauseous."
Correct answer: B
Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.
5. During a client admission, how should the nurse conduct medication reconciliation?
- A. Compare the client’s home medications to the provider's prescriptions.
- B. Review the client’s medical history.
- C. Assess the client's current medications.
- D. Ask the client about their allergies.
Correct answer: A
Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.
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