HESI LPN
Fundamentals HESI
1. Why should a client with an ileal conduit be instructed to empty the collection device frequently?
- A. Force urine to back up into the kidneys.
- B. Suppress production of urine.
- C. Cause the device to pull away from the skin.
- D. Tear the ileal conduit
Correct answer: C
Rationale: A full urine collection bag can cause the device to pull away from the skin, leading to potential leakage and skin irritation. Choice A is incorrect because a full urine collection bag does not force urine to back up into the kidneys. Choice B is incorrect as a full collection bag does not suppress the production of urine. Choice D is incorrect as a full collection bag is unlikely to tear the ileal conduit.
2. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. “I will take a hot bath before going to bed.”
- B. “I will take my new medication in the evening.”
- C. “I will leave a light on in my bathroom at night.”
- D. “I will weigh myself once weekly.”
Correct answer: C
Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.
3. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
- A. The AP hangs the collection bag below the level of the bladder.
- B. The AP performs hand hygiene before handling the catheter.
- C. The AP secures the catheter to the client’s leg with tape.
- D. The AP empties the collection bag when it is full.
Correct answer: A
Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.
4. The healthcare professional is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which action is most important?
- A. Monitor the client's respiratory rate
- B. Check the client's urine output
- C. Administer the potassium chloride as a rapid IV push
- D. Dilute the potassium chloride in an appropriate IV solution
Correct answer: D
Rationale: The correct answer is to dilute the potassium chloride in an appropriate IV solution. Potassium chloride should never be administered as a rapid IV push as it can lead to severe complications, including cardiac arrhythmias. Diluting the medication and administering it slowly helps reduce the risk of adverse effects. Monitoring the client's respiratory rate (Choice A) and checking urine output (Choice B) are important aspects of patient assessment but not the most crucial when administering potassium chloride. Administering potassium chloride as a rapid IV push (Choice C) is dangerous and can result in serious harm to the client.
5. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to:
- A. Check the client’s identification bracelet
- B. Inform the client about the procedure
- C. Prepare the client for transport
- D. Verify the x-ray order
Correct answer: A
Rationale: The correct action to take when a transporter arrives to take a hospitalized client for a procedure is to check the client's identification bracelet. This step is crucial to prevent errors and ensure that the correct patient is receiving the intended procedure. Informing the client about the procedure and preparing them for transport are important steps in the process, but verifying the client's identity takes precedence to ensure patient safety. Verifying the x-ray order, though important, is not the priority action when the transporter arrives; confirming the patient's identity is essential before proceeding with any procedures.
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