HESI LPN
HESI Fundamentals 2023 Test Bank
1. A client is still experiencing mild back pain after receiving analgesia 1 hour ago. Which of the following nonpharmacological pain management techniques should the nurse include in the plan?
- A. Encourage the client to apply a heating pad for 2 hours at a time
- B. Apply an ice pack to the client’s back for 1 hour
- C. Remove distractions from the client’s room
- D. Instruct the client to take deep, rhythmic breaths
Correct answer: D
Rationale: In this scenario, the nurse should instruct the client to take deep, rhythmic breaths as a nonpharmacological pain management technique. Deep, rhythmic breathing helps with relaxation and pain management, potentially reducing the perception of pain. Encouraging the client to apply a heating pad for 2 hours at a time (Choice A) is not recommended as prolonged heat application can lead to tissue damage and is not suitable for mild back pain. Applying an ice pack for 1 hour (Choice B) may not be appropriate for mild back pain as cold therapy is more commonly used for acute injuries. Removing distractions from the client’s room (Choice C) may help create a more calming environment, but it does not directly address the client's pain.
2. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain feel like burning or aching?
- C. Is the pain constant or intermittent?
- D. Does the pain feel like throbbing or stabbing?
Correct answer: A
Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.
3. The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
- A. Observe the appearance of the skin under the ice pack.
- B. Instruct the client regarding the importance of the covering.
- C. Reapply the covering after filling it with fresh ice.
- D. Ask the client how long the ice pack was applied to the skin.
Correct answer: A
Rationale: The correct first action for the nurse to take when a client removes the covering from an ice pack is to observe the appearance of the skin under the ice pack. This assessment is crucial to check for any skin damage or adverse reactions resulting from direct contact with the ice pack. Instructing the client about the importance of the covering (Choice B) can follow the skin assessment. Reapplying the covering (Choice C) before skin assessment may potentially cause harm. Asking the client about the duration of ice application (Choice D) is not the immediate priority; ensuring skin integrity is the primary concern.
4. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?
- A. The parents' name and telephone number
- B. The currency of the immunization and allergy history of the child
- C. The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
- D. The affected child's age and weight
Correct answer: D
Rationale: In the event of accidental poisoning, it is crucial to know the child's age and weight to determine the appropriate treatment. This information helps healthcare providers calculate the correct dosage of antidotes or medications needed based on the child's size and age. The child's age and weight play a significant role in managing accidental poisoning cases. Therefore, this information should be a priority for parents to communicate in such emergencies. Choices A, B, and C are not as critical as the child's age and weight when it comes to immediate treatment decisions for accidental poisoning.
5. During an admission assessment of an older adult client, a nurse should identify which of the following findings as a potential indication of abuse?
- A. Bruises on the arms in various stages of healing
- B. Recent weight gain
- C. Complaints of joint pain
- D. Frequent visits to different providers
Correct answer: A
Rationale: Bruises on the arms in various stages of healing should be identified as a potential indication of abuse in an older adult. These bruises may suggest physical harm or neglect, which are concerning signs of abuse. Recent weight gain (Choice B) is not typically associated with abuse and can have various causes, such as dietary changes or health conditions. Complaints of joint pain (Choice C) are more likely related to musculoskeletal issues rather than abuse. Frequent visits to different providers (Choice D) could indicate seeking multiple opinions or healthcare needs and do not necessarily point to abuse.
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