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. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?
- A. Dandruff
- B. Alopecia
- C. Pediculosis
- D. Xerostomia
Correct answer: A
Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.
3. A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?
- A. Carbon monoxide does not have a distinct odor.
- B. Water heaters should be inspected every 5 years.
- C. The lungs are not damaged from carbon monoxide inhalation.
- D. Carbon monoxide binds with hemoglobin in the body.
Correct answer: D
Rationale: The correct answer is D: 'Carbon monoxide binds with hemoglobin in the body.' Carbon monoxide is an odorless, colorless gas, so it does not have a distinct odor (Choice A). While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning (Choice B). Carbon monoxide primarily affects the cardiovascular system by binding with hemoglobin, reducing the blood's ability to carry oxygen, rather than causing direct lung damage (Choice C). Understanding how carbon monoxide binds with hemoglobin is crucial in recognizing the mechanism of poisoning and its potential consequences.
4. What action should be taken to maintain the patency of a peripherally inserted central catheter (PICC)?
- A. Flush the catheter with heparin solution daily.
- B. Change the dressing at the insertion site daily.
- C. Use sterile technique when changing the dressing.
- D. Keep the insertion site dry at all times.
Correct answer: C
Rationale: The correct answer is to use sterile technique when changing the dressing. This practice is essential for preventing infections that can compromise the patency of the PICC line. While flushing the catheter with heparin solution helps prevent clot formation, it does not directly maintain patency. Changing the dressing daily is important for hygiene but does not have a direct impact on catheter patency. Keeping the insertion site dry is crucial to prevent infections but does not specifically address patency maintenance.
5. A group of newly licensed nurses is being taught about the Braden Scale by a nurse. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?
- A. “The client’s age is not a factor in the measurement.”
- B. “The scale measures six elements.”
- C. “A lower score indicates a higher risk of pressure ulcers.”
- D. “Each element is scored on a range from 1 to 4 points.”
Correct answer: B
Rationale: Choice B is the correct answer because the Braden Scale measures six elements: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction, and Shear. The other choices are incorrect because: Choice A states that the client's age is not a factor in the measurement, which is accurate as age is not included in the Braden Scale. Choice C incorrectly states that a lower score indicates a higher risk of pressure ulcers, which is the opposite of how the Braden Scale works. Choice D inaccurately describes the scoring range of each element on the Braden Scale, which is not from 1 to 4 points but rather from 1 to 3.
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