HESI LPN
HESI Fundamentals Exam Test Bank Questions
Question 1 of 5
A client has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Correct Answer: B
Rationale: Postural drainage is a technique used to help remove secretions from specific lung segments. For left lower atelectasis, placing the client in the right lateral Trendelenburg position is most effective. This position helps target the affected area, using gravity to assist in drainage. Placing the client in a supine or low Fowler's position (Choice A) may not effectively target the affected area. Side lying with the right side of the chest elevated (Choice C) would not utilize gravity for optimal drainage. Placing the client prone with pillows under the extremities (Choice D) is not ideal for postural drainage of the left lower lobe.
Question 2 of 5
A nurse is providing care to a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent catheter-associated urinary tract infections (CAUTIs)?
Correct Answer: D
Rationale: Securing the catheter to the client's thigh is the correct action to prevent CAUTIs. By securing the catheter, movement is minimized, reducing the risk of introducing bacteria into the urinary tract. Choice A is incorrect because routine irrigation of the catheter is not recommended as it can increase the risk of infection. Choice B is incorrect as emptying the catheter bag every 8 hours is important for proper drainage but does not directly prevent CAUTIs. Choice C is incorrect because cleaning the perineal area with antiseptic solution does not address the main source of CAUTIs related to catheter care.
Question 3 of 5
During a home safety assessment for a client receiving supplemental oxygen, which observation should the nurse identify as proper safety protocol?
Correct Answer: A
Rationale: The correct answer is A. Using non-acetone nail polish remover is crucial for clients on supplemental oxygen as acetone is flammable and poses a safety risk. Acetone can react with oxygen, increasing the fire hazard. Choices B, C, and D are incorrect. Electric razors can generate sparks, which are dangerous near oxygen due to the risk of ignition. While cleaning oxygen equipment is important, the type of nail polish remover used is more critical for immediate safety. Wool blankets can create static electricity, increasing the risk of fire around oxygen due to its flammability.
Question 4 of 5
A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?
Correct Answer: D
Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.
Question 5 of 5
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
Correct Answer: B
Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.