HESI LPN
HESI Fundamentals Exam
1. A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?
- A. It decreases the risk of injecting medication into a blood vessel.
- B. It delays medication absorption.
- C. It minimizes tissue irritation.
- D. It accelerates medication excretion.
Correct answer: C
Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.
2. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
- A. Immediately after exhalation.
- B. During the inhalation.
- C. At the end of three inhalations.
- D. Immediately after inhalation.
Correct answer: B
Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.
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 postoperative expresses pain during dressing changes. What should the nurse prioritize?
- A. Administer pain medication 45 minutes before changing the client’s dressing.
- B. Change the dressing less frequently.
- C. Apply a topical anesthetic before removing the dressing.
- D. Use a non-adherent dressing to reduce pain.
Correct answer: A
Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.
5. When assessing a patient's feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition?
- A. Fungi
- B. Friction
- C. Nail polish
- D. Nail polish remover
Correct answer: A
Rationale: The nurse would most likely suspect fungi as the cause of thickened and separated toenails. Fungal infections can lead to changes in the nail structure, causing them to thicken and separate from the nail bed. Friction, nail polish, and nail polish remover are less likely to cause these specific nail changes. Friction typically leads to calluses or blisters, while nail polish and nail polish remover do not commonly result in thickened and separated toenails.
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