HESI LPN
HESI Fundamentals Test Bank
1. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?
- A. Pull down and out at the back of the upper denture to remove.
- B. Brush the dentures with a toothbrush and denture cleaner.
- C. Rinse the dentures with hot water after cleaning them.
- D. Place the dentures in a clean, dry storage container after cleaning them.
Correct answer: B
Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.
2. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?
- A. Complete the intermittent suction of the nasopharynx.
- B. Reposition the pulse oximeter clip to obtain a new reading.
- C. Stop suctioning until the pulse oximeter reading is above 95%.
- D. Apply an oxygen mask over the client's nose and mouth.
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.
3. Which action is most important for maintaining sterility when donning sterile gloves?
- A. Maintain thumbs at a ninety-degree angle.
- B. Hold hands with fingers pointing downward while gloving.
- C. Keep gloved hands above the elbows.
- D. Put the glove on the dominant hand first.
Correct answer: C
Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.
4. The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Dangle the patient at the bedside.
- C. Encourage isometric exercises.
- D. Suggest a high-calcium diet.
Correct answer: B
Rationale: The correct action the nurse should take first when a patient needs to be mobilized after being in bed for several days is to dangle the patient at the bedside. Dangling at the bedside is the initial step to assess the patient's tolerance to sitting up and moving. It helps prevent orthostatic hypotension and allows the nurse to evaluate the patient's response to upright positioning before attempting further ambulation. Maintaining a narrow base of support (Choice A) is related to assisting with ambulation but is not the first step. Encouraging isometric exercises (Choice C) and suggesting a high-calcium diet (Choice D) are not immediate actions needed to initiate mobilization in this scenario.
5. When assessing a client's skin turgor, a nurse should:
- A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
- B. Check skin elasticity on the back of the hand
- C. Press on the skin over the abdomen
- D. Measure skin turgor on the lower leg
Correct answer: A
Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.
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