HESI LPN
HESI Fundamentals 2023 Test Bank
1. During an IV catheter insertion demonstration, which statement by a nurse indicates understanding of the procedure?
- A. “I will thread the needle into the vein at an angle of 10 to 30 degrees with the bevel up.”
- B. “I will insert the needle into the client’s skin at an angle of 10 to 30 degrees with the bevel up.”
- C. “I will apply pressure approximately 1.2 inches below the insertion site before removing the needle.”
- D. “I will select a vein in the antecubital fossa for IV insertion based on its size and easily accessible location.”
Correct answer: B
Rationale: The correct technique for IV catheter insertion involves inserting the needle at a 10 to 30-degree angle with the bevel up. This angle facilitates proper vein puncture, reduces the risk of complications, and minimizes trauma to the vein. Choice A is incorrect because threading the needle into the vein at an angle of 10 to 30 degrees with the bevel up is the correct technique, not threading it all the way into the vein. Choice C is incorrect because applying pressure 1.2 inches below the insertion site before removing the needle is not a standard step in IV catheter insertion. Choice D is incorrect because selecting the antecubital fossa vein solely based on its size and accessibility may not be the most appropriate criterion; vein selection should also consider factors like vein condition and patient comfort.
2. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?
- A. Corns
- B. A callus
- C. Plantar warts
- D. Athlete's foot
Correct answer: C
Rationale: The nurse most likely observed plantar warts, which appear on the sole of the foot and are caused by the papillomavirus. Corns (Choice A) and calluses (Choice B) are areas of thickened skin caused by pressure or friction and are not typically associated with viruses. Athlete's foot (Choice D) is a fungal infection that usually affects the skin between the toes and is not caused by a virus like plantar warts.
3. A healthcare professional is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
- A. Ventrogluteal
- B. Dorsogluteal
- C. Deltoid
- D. Vastus lateralis
Correct answer: A
Rationale: The ventrogluteal site is considered the safest for intramuscular injections in young adult clients due to its location away from major nerves and blood vessels. The ventrogluteal site is preferred over the dorsogluteal site, as the latter is associated with a higher risk of injury to the sciatic nerve. The deltoid site is commonly used for vaccines but may not be suitable for all intramuscular injections due to smaller muscle mass. The vastus lateralis site is often used in infants and young children, but in young adults, the ventrogluteal site is preferred for safety and efficacy.
4. A healthcare professional is planning care to improve self-feeding for a client with vision loss. Which of the following interventions should the healthcare professional include in the plan of care?
- A. Instruct the client on the sequence of foods to eat first
- B. Offer small-handle utensils for the client to use
- C. Thicken liquids served to the client
- D. Use a clock pattern to indicate food placement on the client's plate
Correct answer: D
Rationale: The correct answer is D. When a client has vision loss, using a clock pattern to describe food placement on the plate can facilitate independent eating. This method enables the client to locate different food items based on their positions, enhancing self-feeding abilities. Instructing the client on the sequence of foods to eat first (Choice A) may not address the visual impairment directly. Providing small-handle utensils (Choice B) can be helpful for clients with limited dexterity but may not specifically assist a client with vision loss. Thickening liquids (Choice C) is more relevant for clients with dysphagia, not vision loss.
5. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?
- A. Impaired balance
- B. Hemiplegia
- C. Muscle sprain
- D. Lower extremity paralysis
Correct answer: A
Rationale: When the cerebellum is damaged, it leads to impaired balance. The cerebellum plays a crucial role in coordinating movements and maintaining balance. Therefore, assessing the patient's balance is essential in determining the extent of cerebellar damage. Options B, C, and D are incorrect because hemiplegia refers to paralysis of one side of the body, muscle sprain is a soft tissue injury, and lower extremity paralysis involves loss of function in the lower limbs. These conditions are not directly associated with damage to the cerebellum.
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