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. A nurse is caring for a competent adult client who tells the nurse, 'I am leaving the hospital this morning whether the doctor discharges me or not.' The nurse believes that this is not in the client’s best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct answer: B
Rationale: The nurse is about to commit false imprisonment by unlawfully restricting the client's freedom of movement. In this scenario, the nurse's actions of preparing to administer sedative medication against the client's will in an effort to prevent them from leaving the hospital constitute false imprisonment. Assault (choice A) involves the threat of bodily harm, which is not present here. Negligence (choice C) refers to a breach in the duty of care, which is not the primary issue in this situation. Breach of confidentiality (choice D) involves disclosing confidential information without consent, which is unrelated to the scenario described.
3. If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?
- A. “I will get the caller off the phone as soon as possible so I can alert the staff.”
- B. “I will begin evacuating clients using the elevators.”
- C. “I will not ask any questions and just let the caller talk.”
- D. “I will listen for background noises.”
Correct answer: D
Rationale: The correct answer is D: “I will listen for background noises.” Listening for background noises can provide useful information about the bomb’s location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.
4. A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?
- A. Daily weight
- B. Intake and output
- C. Urine specific gravity
- D. Peripheral edema
Correct answer: A
Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.
5. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?
- A. Place the pillow under the patient's head and shoulders.
- B. Attempt to do it alone if the bed is in a flat position.
- C. Place the side rails in the up position.
- D. Use a friction-reducing device.
Correct answer: D
Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.
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