HESI LPN
Fundamentals HESI
1. During an abdominal assessment for an adult client, what is the correct sequence of steps?
- A. Inspect, Auscultate, Percuss, Palpate
- B. Palpate, Percuss, Inspect, Auscultate
- C. Auscultate, Inspect, Percuss, Palpate
- D. Percuss, Palpate, Inspect, Auscultate
Correct answer: A
Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.
2. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include?
- A. Avoid taping electrical cords to the floor.
- B. Clean electrical equipment before disconnection.
- C. Cover exposed wires with tape before use.
- D. Disconnect electrical equipment by grasping the plug.
Correct answer: A
Rationale: The correct instruction for electrical safety is to avoid taping electrical cords to the floor. Taping cords can create tripping hazards, leading to falls and potential injuries. Choice B, cleaning electrical equipment before disconnection, is not directly related to electrical safety but rather to equipment maintenance. Choice C, covering exposed wires with tape before use, is incorrect as exposed wires should be properly insulated and repaired by a qualified professional. Choice D, disconnecting electrical equipment by grasping the plug, is unsafe and can lead to electrical shocks. It is always recommended to unplug devices by holding the plug itself, not by pulling the cord.
3. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?
- A. Tea
- B. Water
- C. Milk
- D. Soda
Correct answer: B
Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.
4. A client who has a terminal illness asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
- A. Encourage the client to express their thoughts about death and dying
- B. Share the nurse's personal beliefs about death and dying
- C. Redirect the client to a chaplain or spiritual advisor
- D. Provide a brief overview of common religious beliefs about death and dying
Correct answer: A
Rationale: Encouraging the client to express their thoughts allows them to explore their own feelings and concerns about death. This approach empowers the client to reflect on their beliefs and values without the influence of the nurse's personal beliefs (choice B), which should remain separate in a professional setting. Redirecting the client to a chaplain or spiritual advisor (choice C) may be appropriate if the client seeks specific spiritual guidance. Providing a brief overview of common religious beliefs (choice D) may not address the client's individual questions and concerns.
5. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?
- A. Remove the gloves carefully and follow with hand hygiene
- B. Change gloves and continue
- C. Wash hands immediately without removing gloves
- D. Report the incident to the supervisor
Correct answer: A
Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.
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