HESI LPN
HESI Fundamentals 2023 Test Bank
1. A healthcare provider is preparing to provide hygiene care. Which principle should the provider consider when planning hygiene care?
- A. Hygiene care is not performed in the same way by all individuals.
- B. No two individuals perform hygiene in the same manner.
- C. Standardizing a patient's hygienic practices is crucial.
- D. Understanding patient needs is not essential during hygiene care.
Correct answer: B
Rationale: The correct answer is B: 'No two individuals perform hygiene in the same manner.' It is crucial to individualize a patient's care based on understanding the patient's unique hygiene practices and preferences. Choice A is incorrect because hygiene care should be tailored to the individual's needs and preferences, not seen as routine and expected for everyone. Choice C is incorrect as standardizing a patient's hygienic practices may not address their specific needs. Choice D is incorrect because understanding patient needs is essential during hygiene care to provide personalized and effective care.
2. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:
- A. Cleanse the entry port prior to withdrawing urine.
- B. Use a sterile syringe to collect urine from the collection bag.
- C. Obtain the specimen from the drainage tubing.
- D. Replace the catheter before obtaining the specimen.
Correct answer: A
Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.
3. A healthcare provider is providing discharge teaching to a client about self-administering heparin.
- A. Administer medication in the abdomen.
- B. Administer medication in the thigh.
- C. Administer medication in the upper arm.
- D. Administer medication in the buttock.
Correct answer: A
Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.
4. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
- A. “The client’s age is not a factor in the measurement.”
- B. “The scale measures six elements.”
- C. “A lower score indicates a higher risk of pressure ulcers.”
- D. “Each element is scored on a range from 1 to 4 points.”
Correct answer: B
Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.
5. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?
- A. Knee picture
- B. Ankle picture
- C. Elbow picture
- D. Wrist picture
Correct answer: A
Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.
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