HESI LPN
Fundamentals HESI
1. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area?
- A. Roof of mouth, gums, and inside cheeks
- B. Chewing and inner tooth surfaces
- C. Outer tooth surfaces
- D. Tongue
Correct answer: C
Rationale: The correct sequence for oral care is to clean the outer tooth surfaces first, followed by cleaning the inner tooth surfaces, then the roof of the mouth, gums, and inside cheeks with a toothette. Brushing the tongue should be the final step in the oral care procedure. Therefore, option C is the correct choice. Options A, B, and D are incorrect because they do not follow the correct order for providing oral care to a patient.
2. A client is scheduled for hip surgery in an hour. Which of the following actions is the nurse’s priority?
- A. Ensure that the client signs the consent form.
- B. Lock the client’s valuables in a secure location.
- C. Verify the client’s lab values in the medical record.
- D. Administer the prescribed preoperative sedative.
Correct answer: A
Rationale: The nurse’s priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client’s right to make decisions about their care.
3. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?
- A. I will only have to wear this for 6 months.
- B. I should inspect my skin daily.
- C. The brace will be worn day and night.
- D. I can take it off when I shower.
Correct answer: A
Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.
4. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?
- A. Help the client write down the questions to ask the provider, so that the client doesn’t forget
- B. Reassure the client that everything will be explained
- C. Explain the procedure in detail yourself
- D. Direct the client to search for information online
Correct answer: A
Rationale: Assisting the client in preparing questions is the most appropriate action as it helps ensure that all concerns are addressed during the provider's visit. By helping the client write down questions, the nurse empowers the client to actively participate in their care and communicate effectively with the provider. Reassuring the client, while well-intentioned, may not address the specific questions or fears the client has. Explaining the procedure in detail may not be what the client is seeking at this moment, as their primary concern is about the provider's actions. Directing the client to search for information online is not recommended as it may lead to confusion or misinformation, and the information may not be tailored to the client's specific situation.
5. When should the nurse plan to collect a sputum specimen for culture and sensitivity as ordered by a client's provider?
- A. In the morning upon rising.
- B. Immediately after the client eats breakfast.
- C. Before the client goes to bed.
- D. After the client has had a drink of water.
Correct answer: A
Rationale: The correct time to collect a sputum specimen for culture and sensitivity is in the morning upon rising. This timing ensures the most concentrated sample as sputum produced overnight tends to accumulate and sit in the airways, providing a quality sample for testing. Collecting the specimen immediately after eating breakfast (choice B) may introduce food particles that could contaminate the sample. Collecting it before bed (choice C) may lead to a diluted sample due to daily activities. Collecting the specimen after having a drink of water (choice D) can also result in a diluted sample, impacting the accuracy of the test results.
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