HESI LPN
HESI Fundamentals Exam Test Bank
1. Before donning gloves to perform a procedure, proper hand hygiene is essential. The healthcare professional understands that the most important aspect of hand hygiene is the amount of:
- A. Temperature
- B. Time
- C. Friction
- D. Soap
Correct answer: C
Rationale: The correct answer is C: Friction. The amount of friction is crucial in effective hand hygiene to remove microorganisms. Rubbing hands together with friction helps to dislodge and remove dirt, oils, and microorganisms. While temperature and soap are important factors in hand hygiene, the mechanical action of friction plays a more significant role in physically removing contaminants. Time is also important in hand hygiene practice, but without adequate friction, the effectiveness of the process is compromised.
2. When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?
- A. Lock the wheels on both the bed and stretcher
- B. Adjust the bed to a low position
- C. Ask the client to assist in the transfer
- D. Use a transfer sheet without locking the wheels
Correct answer: A
Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.
3. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?
- A. Obtain assistance and physically transfer the patient to the chair.
- B. Assist with ambulation and measure how far the patient walks.
- C. Give pain medication after ambulation so the patient will have a clear mind.
- D. Bring the patient to the cafeteria for group instruction on ambulation.
Correct answer: B
Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.
4. While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:
- A. Ask the client if they are choking
- B. Perform abdominal thrusts
- C. Call for emergency help
- D. Check the client’s airway
Correct answer: A
Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.
5. A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Remove sutures using sterile technique.
- C. Inspect the wound for signs of infection.
- D. Document the removal of sutures.
Correct answer: B
Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI LPN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access