a nurse is teaching a client with a new colostomy about how to irrigate the ostomy the nurse realizes that the client needs further teaching when the
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A client with a new colostomy is being taught how to irrigate the ostomy. The healthcare provider realizes that the client needs further teaching when the client:

Correct answer: A

Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.

2. A client is evaluated by a nurse regarding the use of a sequential compression device. Which of the following client statements indicates understanding of the device's purpose?

Correct answer: B

Rationale: The correct answer is B because sequential compression devices are utilized to enhance circulation and prevent clot formation in the legs. Option A is incorrect because these devices are not primarily meant to prevent skin sores. Option C is incorrect because the devices do not directly address muscle weakness. Option D is incorrect as the main purpose of sequential compression devices is not related to joint health.

3. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

4. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

5. A nurse at a provider’s office is discussing routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?

Correct answer: B

Rationale: The correct answer is B. Mammograms are recommended annually for women starting at age 40 or 45. This statement aligns with current guidelines for breast cancer screening in women without specific risk factors. Choice A is incorrect because colon cancer screenings are typically recommended at different intervals. Choice C is incorrect as Pap smears are usually done every 3-5 years based on age and risk factors. Choice D is incorrect because glucose testing is usually recommended more frequently, especially for individuals at risk for diabetes mellitus.

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