HESI LPN
Fundamentals of Nursing HESI
1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct answer: A
Rationale: The correct answer is A: Assault. Assault involves making threats or using actions that cause the client to fear harm. In this scenario, the AP's threat to use diapers next time the urinal is used improperly constitutes as assault. Choice B, Battery, involves intentional harmful or offensive touching without consent, which is not evident in the scenario. Choice C, False imprisonment, refers to restraining or restricting a client's freedom of movement, which is not occurring in this situation. Choice D, Invasion of privacy, involves violating a client's right to privacy, which is also not applicable here.
2. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?
- A. Use a 25-gauge needle.
- B. Select a site on the client’s abdomen.
- C. Use the Z-track technique to displace the skin on the injection site.
- D. Observe for bleb formation to confirm proper placement.
Correct answer: B
Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.
3. A healthcare professional is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the healthcare professional question?
- A. Oral psyllium (Metamucil)
- B. Oral potassium supplement
- C. Parenteral half normal saline
- D. Parenteral albumin (Albuminar)
Correct answer: D
Rationale: The correct answer is D, Parenteral albumin (Albuminar). Parenteral albumin is not typically indicated for dehydration resulting from diarrhea. In this case, fluid replacement therapy with intravenous fluids such as parenteral half normal saline would be more appropriate. Oral psyllium and oral potassium supplement are not the primary interventions for managing dehydration due to watery diarrhea. Oral psyllium is a fiber supplement used for constipation rather than diarrhea. Oral potassium supplements may be necessary if potassium levels are low due to dehydration, but the priority is fluid replacement. Therefore, choices A and B are less relevant in this scenario.
4. A healthcare provider is providing discharge teaching to a client who does not speak the same language. Which of the following actions should the healthcare provider take?
- A. Use proper medical terms when providing instructions to the client.
- B. Offer written instructions in the client’s language.
- C. Direct verbal discharge instructions to the interpreter.
- D. Request that an assistive personnel interpret instructions for the client.
Correct answer: B
Rationale: The correct action for the healthcare provider when providing discharge teaching to a client who does not speak the same language is to offer written instructions in the client’s language. This approach helps ensure better comprehension and adherence to the instructions as the client can refer back to the written material for clarification. Choice A is incorrect because using proper medical terms may not be effective if the client does not understand the language. Choice C is incorrect since verbal instructions should be directed to the client for better understanding. Choice D is incorrect as assistive personnel may not be qualified or trained to provide accurate interpretation, risking miscommunication and potential errors in the instructions.
5. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed.
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client’s blood pressure and pulse deficit
Correct answer: D
Rationale: Checking the client’s blood pressure and pulse deficit is essential before mobilizing a client out of bed, especially after surgery. This assessment helps ensure the client's stability and readiness for mobilization. Administering oxygen or pivoting the client without prior assessment could pose risks if the client is not medically stable. Helping the client lie back down without proper evaluation may delay necessary interventions if the client is indeed ready for mobilization.
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