HESI LPN
HESI Fundamentals Exam
1. The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?
- A. Arm
- B. Hip
- C. Back
- D. Ankle
Correct answer: C
Rationale: The correct answer is C: Back. Back injuries are common among healthcare workers, especially nurses, due to improper lifting techniques and bending. Working on an orthopedic rehabilitation unit involves frequent lifting and positioning of patients, putting the nurse at risk of back injuries. Preventing back injuries is crucial for maintaining the nurse's health and ability to provide care effectively. Choices A, B, and D are incorrect because while lifting and positioning patients may involve these body parts, back injuries are most likely to occur due to the strain and stress placed on the back during such activities.
2. While observing a student nurse administering a narcotic analgesic IM injection without aspirating, what should the nurse do?
- A. Ask the student, 'What did you forget to do?'
- B. Stop and explain why aspiration is needed.
- C. Quietly state, 'You forgot to aspirate.'
- D. Walk up and whisper in the student's ear, 'Stop. Aspirate. Then inject.'
Correct answer: D
Rationale: When the nurse observes a student nurse making a mistake during a procedure, such as not aspirating before administering a medication, the nurse should provide immediate, discreet feedback to correct the error. Walking up and whispering in the student's ear to stop, aspirate, and then inject is appropriate as it corrects the mistake while maintaining the student's dignity and confidence. Option A is not as effective as it indirectly addresses the issue. Option B is not the best approach as the student needs immediate correction. Option C is not ideal as loudly stating the mistake may embarrass the student and is not necessary for a discreet correction.
3. A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?
- A. 8 oz of ice chips
- B. 8 oz of ice chips
- C. 1 cup of broth
- D. 1 cup of broth
Correct answer: A
Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.
4. To use the nursing process correctly, what must the nurse do first?
- A. Obtain information about the client
- B. Develop a care plan
- C. Implement interventions
- D. Evaluate the client's outcomes
Correct answer: A
Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.
5. A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
- A. Cough deeply after each use.
- B. Take a deep breath and hold for 10 seconds.
- C. Breathe in slowly and deeply to raise the ball or piston.
- D. Exhale forcefully before using the spirometer.
Correct answer: C
Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.
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