an elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube the lpn knows that the best positio
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HESI LPN

HESI Fundamentals Practice Questions

1. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is

Correct answer: B

Rationale: Fowler's position is the optimal position for a client receiving tube feedings via a gastrostomy tube because it reduces the risk of aspiration. In Fowler's position, the client is sitting up at a 45- to 60-degree angle, which helps prevent the formula from flowing back into the esophagus and causing aspiration pneumonia. Choice A, prone position (lying face down), would not be suitable for administering tube feedings as it increases the risk of aspiration. Sims' position (lying on the left side with the right knee flexed) and supine position (lying flat on the back) are also not ideal for administering tube feedings as they do not provide the same level of protection against aspiration as Fowler's position does.

2. When performing cardiac chest compressions, what is a critical concept that the nurse must understand?

Correct answer: A

Rationale: The correct answer is to 'Push hard and deep on the chest.' Effective chest compressions during CPR should be forceful and deep enough to adequately circulate blood to vital organs. This helps maintain perfusion and increases the likelihood of a successful outcome. Compressing the chest at a rapid rate (choice B) is important but not as critical as ensuring the compressions are hard and deep. Performing compressions with minimal interruptions (choice C) is also crucial to maintain blood flow. Using a two-handed technique for compressions (choice D) may be helpful but is not as critical as the depth and force of the compressions.

3. When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?

Correct answer: D

Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.

4. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

Correct answer: A

Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.

5. A healthcare professional is assessing an adult client who has been immobile for the past 3 weeks. The healthcare professional should identify that which of the following findings requires further intervention?

Correct answer: A

Rationale: Erythema on pressure points indicates potential skin breakdown due to prolonged immobility. It requires immediate intervention to prevent pressure ulcers. Lower-extremity pulse strength of 2+ is a normal finding, indicating adequate peripheral perfusion. Fluid intake of 3,000 mL per day is within the normal range and promotes hydration. A bowel movement every other day is a reasonable frequency for some individuals and does not necessarily indicate a need for immediate intervention in this scenario.

Similar Questions

The nurse is preparing to administer a medication through a nasogastric (NG) tube. Which action should the LPN/LVN take to ensure proper administration?
A patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?
A nurse is caring for a competent adult client who tells the nurse, 'I am leaving the hospital this morning whether the doctor discharges me or not.' The nurse believes that this is not in the client’s best interest and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?
What is the most important action for preventing infection in a client with a central venous catheter?
The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?

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