HESI LPN
HESI Fundamentals Study Guide
1. The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?
- A. Should be postponed because it may cause embarrassment.
- B. Should be unnecessary because the patient is uncircumcised.
- C. Should be done by the patient.
- D. Should be done by the nurse.
Correct answer: C
Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.
2. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?
- A. Role overload
- B. Role conflict
- C. Role ambiguity
- D. Role strain
Correct answer: A
Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.
3. During a change-of-shift report at a long-term care facility, a nurse discusses an older adult client with shingles with an oncoming nurse. What information should the nurse include in the report?
- A. The location of the client's breakfast.
- B. The schedule for administering routine vital signs.
- C. The specific transmission-based precautions in place.
- D. The type of transmission-based precautions in place.
Correct answer: D
Rationale: The correct answer is to include the type of transmission-based precautions in the report. This information is crucial for infection control when caring for a client with shingles, as it helps prevent the spread of the virus to other clients and healthcare workers. Choices A, B, and C are not directly related to managing a client with shingles. Option A about the location of breakfast is irrelevant to the client's condition. Option B about vital sign measurements, though important, is not the priority when discussing a client with shingles. Option C mentions 'specific times the client had visitors,' which is not as crucial as knowing the specific precautions in place to prevent transmission of the virus.
4. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
- A. The nurse washes with her hands held higher than her elbows.
- B. The nurse uses an alcohol-based hand rub for 30 seconds.
- C. The nurse scrubs hands and forearms for 2 minutes with soap and water.
- D. The nurse washes her hands with soap and water for only 15 seconds.
Correct answer: A
Rationale: Proper surgical hand-washing technique involves washing with the hands held higher than the elbows. This positioning is essential to ensure proper rinsing and to prevent the risk of contamination. Option B, using an alcohol-based hand rub for 30 seconds, is not specific to surgical hand-washing and is more commonly used for routine hand hygiene. Option C, scrubbing hands and forearms for 2 minutes with soap and water, is excessive and not typically required for routine hand-washing. Option D, washing hands with soap and water for only 15 seconds, is insufficient for thorough surgical hand-washing.
5. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?
- A. Spaghetti
- B. Watermelon
- C. Chicken
- D. Tomatoes
Correct answer: B
Rationale: The correct answer is 'Watermelon.' Watermelon is high in potassium, which is important to counteract the potassium loss caused by furosemide. Furosemide is a loop diuretic that can lead to potassium depletion, so consuming potassium-rich foods like watermelon can help maintain electrolyte balance. Choices A, C, and D do not specifically address the need for potassium in this scenario and are not as beneficial for addressing the potential electrolyte imbalance caused by furosemide.
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