HESI LPN
Fundamentals of Nursing HESI
1. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
- A. Members of the same religion may have varying feelings about their religion.
- B. A shared religion background does not guarantee identical beliefs.
- C. The same religious beliefs can influence individuals differently.
- D. Discussing differences and commonalities in beliefs may not always be relevant.
Correct answer: C
Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.
2. During the admission assessment of a terminally ill male client, he states that he is agnostic. What is the best nursing action in response to this statement?
- A. Provide information about the hours and location of the chapel
- B. Document the statement of the client’s spiritual assessment
- C. Invite the client to a healing service for people of all religions
- D. Offer to contact a spiritual advisor of the client’s choice
Correct answer: B
Rationale: The best nursing action in response to a terminally ill client stating their agnostic beliefs is to document the client's spiritual assessment. By documenting this information, the healthcare team can ensure that the client's beliefs are acknowledged and respected in their care plan. Providing information about the chapel's hours or inviting the client to a healing service may not align with the client's beliefs and preferences. Offering to contact a spiritual advisor of the client's choice may not be necessary if the client has clearly stated their agnostic beliefs, as they may not wish to engage in spiritual counseling.
3. When a nurse instructs a client with hearing loss about cleaning their new hearing aids, which statement indicates that the client understands the instructions?
- A. I use a damp cloth to clean the outside part of my hearing aids.
- B. I clean my hearing aids' ear molds with rubbing alcohol.
- C. I always keep the volume of my hearing aids turned up for better hearing.
- D. I remove the batteries from my hearing aids when not in use at night.
Correct answer: A
Rationale: The correct answer is A because cleaning the outside part of hearing aids with a damp cloth is an appropriate method. Rubbing alcohol can damage ear molds, so choice B is incorrect. Keeping the volume of hearing aids turned up high may lead to discomfort, making choice C incorrect. Removing batteries when not in use at night is good practice for battery life, but it does not directly relate to understanding cleaning instructions, so choice D is less relevant in this context.
4. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?
- A. Measure the client's vital signs.
- B. Assess the client's pain level.
- C. Verify the morphine order with another nurse.
- D. Check the client's last dose of morphine.
Correct answer: A
Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.
5. What is the first step a healthcare professional should take when preparing to provide tracheostomy care?
- A. Perform hand hygiene
- B. Gather equipment
- C. Explain the procedure
- D. Assess the client
Correct answer: A
Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.
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