HESI LPN
HESI CAT
1. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
- A. Go to the emergency room to have blood drawn
- B. Prepare the medication using a new syringe
- C. Apply clean gloves before giving the medication
- D. Review the medical history in the client's chart
Correct answer: B
Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
2. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)
- A. Decrease laxative use to every other day and use oil retention enemas as needed.
- B. Include oatmeal with stewed prunes for breakfast as often as possible.
- C. Increase fluid intake by keeping a water glass next to the recliner.
- D. Recommend seeking help with regular shopping and meal preparation.
Correct answer: C
Rationale: The correct answer is C. Increasing fluid intake is essential for managing constipation. Adequate hydration helps soften stool and promotes bowel movements. Choices A and B are incorrect as decreasing laxative use without medical advice and suggesting specific foods like oatmeal with stewed prunes may not be suitable for every individual with constipation. Choice D is also incorrect as while seeking help with meal preparation can indirectly aid in managing constipation, the immediate need is to increase fluid intake.
3. The nurse is providing discharge teaching to a client who has undergone abdominal surgery. What instruction should the nurse include?
- A. Avoid heavy lifting for at least 6 weeks
- B. Limit fluid intake to reduce the risk of infection
- C. Resume normal activities as soon as possible
- D. Avoid driving for at least 2 weeks
Correct answer: A
Rationale: The correct answer is A: 'Avoid heavy lifting for at least 6 weeks.' After abdominal surgery, it is essential to avoid heavy lifting to prevent complications such as incisional hernias and support proper healing. Choice B, 'Limit fluid intake to reduce the risk of infection,' is incorrect because adequate fluid intake is necessary for wound healing and preventing dehydration. Choice C, 'Resume normal activities as soon as possible,' is incorrect as it may increase the risk of complications and delay healing. Choice D, 'Avoid driving for at least 2 weeks,' is incorrect as the restriction on driving may vary depending on the type of surgery and individual recovery.
4. A female client is admitted for a diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet?
- A. Understands the importance of timing insulin administration 30 minutes before eating
- B. Frequently includes fruits and vegetables in meals and snacks
- C. Has access to someone who can assist with meal preparation and monitoring
- D. Demonstrates willingness to consistently follow the prescribed diet
Correct answer: D
Rationale: The most crucial characteristic for successful adherence to a diabetic diet is the client's willingness to consistently follow the prescribed diet plan. Option A, understanding insulin timing, is important for treatment but not directly related to dietary adherence. Option B, consuming fruits and vegetables, is a healthy practice but does not ensure adherence to a specific diabetic diet. Option C, having assistance with meal preparation, is beneficial but not as essential as the client's personal commitment to adhering to the diet consistently.
5. Which behavior is most likely to result in a breach of client confidentiality?
- A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
- B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
- C. Nursing students on the same team discussing their assigned client’s conditions
- D. A registered nurse privately sharing personal feelings about a client with another nurse on the team
Correct answer: B
Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.
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