HESI LPN
HESI Fundamentals Exam
1. The healthcare provider is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the healthcare provider use when reporting to the oncoming shift?
- A. Cheilitis
- B. Halitosis
- C. Glossitis
- D. Dental caries
Correct answer: B
Rationale: The correct term the healthcare provider will use when reporting the extremely bad breath of the unconscious patient to the oncoming shift is 'Halitosis' (Choice B). Halitosis specifically refers to bad breath. Cheilitis (Choice A) is inflammation of the lips, not related to bad breath. Glossitis (Choice C) is inflammation of the tongue, not directly associated with bad breath. Dental caries (Choice D) are cavities in the teeth, which can contribute to bad breath but are not the term used to describe bad breath itself.
2. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?
- A. Assume a decision-making role
- B. Seek input from staff
- C. Use a non-directive approach
- D. Shared decision-making with others
Correct answer: A
Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.
3. During an admission history assessment, a client informs the nurse about consuming herbal tea every afternoon at work to alleviate stress. What ingredient is likely present in the tea?
- A. Chamomile
- B. Ginseng
- C. Ginger
- D. Echinacea
Correct answer: A
Rationale: The correct answer is A: Chamomile. Chamomile tea is commonly used for stress relief. Choice B, Ginseng, is not typically used in teas for stress relief but for energy and immune system support. Choice C, Ginger, is more commonly used for digestive health and nausea. Choice D, Echinacea, is often used to boost the immune system. Therefore, in the context of stress relief, Chamomile is the most appropriate ingredient.
4. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight, and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take?
- A. Ask the client if he is okay.
- B. Call security from the room.
- C. Find out if there is anyone else in the room.
- D. Ask security to make sure the room is safe.
Correct answer: D
Rationale: The most critical action for the LPN/LVN to take in this situation is to ask security to ensure the room is safe. This step is crucial to prevent any further harm to the unconscious client or others. While it is important to assess the client's condition, ensuring safety takes precedence. Calling security from the room may expose the LPN/LVN to potential danger without confirming the safety of the environment first. Finding out if anyone else is in the room can wait until safety is established to avoid unnecessary risks.
5. A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?
- A. Notify the manufacturer
- B. Disconnect the machine, and measure the blood pressure manually every 15 min
- C. Adjust the machine settings again
- D. Ignore the extra readings
Correct answer: B
Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.
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