HESI LPN
Fundamentals of Nursing HESI
1. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning?
- A. Case manager - responsible for overseeing a case load of clients but does not provide direct client care
- B. Client educator
- C. Client advocate
- D. Supervisor
Correct answer: D
Rationale: The correct answer is D: Supervisor. In this scenario, the nurse manager is acting as a supervisor to oversee and ensure the newly licensed nurse performs the straight catheterization correctly, following protocols, and maintaining client safety. A supervisor role involves monitoring and guiding staff in their duties to ensure quality care. Choices A, B, and C are incorrect. A case manager typically manages a case load of clients but does not provide direct care like in this situation. Client educator and client advocate roles do not directly relate to supervising or overseeing a procedure being performed by another nurse.
2. The nurse is caring for an older adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment, the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?
- A. These are normal signs of aging.
- B. These are early signs of dementia.
- C. These are purely psychological in origin.
- D. These are common manifestations with UTIs.
Correct answer: D
Rationale: The nurse should interpret confusion and agitation in an older adult patient with a UTI as common manifestations of the infection. In older patients, confusion is a primary symptom of a compromised state due to an acute urinary tract infection or fever. Choice A is incorrect as confusion and agitation are not normal signs of aging. Choice B is incorrect because these symptoms are more likely related to the UTI rather than early signs of dementia. Choice C is incorrect as confusion and agitation in this context are not purely psychological but are likely physiological responses to the UTI.
3. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?
- A. Measure the client's urine output.
- B. Auscultate the client's lung sounds.
- C. Assess the client's apical pulse.
- D. Check the client's blood pressure.
Correct answer: B
Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.
4. A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?
- A. Offer to assist the client who needs the bedpan.
- B. Administer the injection the other nurse prepared.
- C. Prepare another syringe and administer the injection.
- D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.
Correct answer: C
Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.
5. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?
- A. Role overload
- B. Role conflict
- C. Role ambiguity
- D. Role strain
Correct answer: A
Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.
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