HESI LPN
HESI Fundamentals 2023 Test Bank Questions
Question 1 of 5
A client who is 3 days post-op following a cholecystectomy has yellow and thick drainage on the dressing. The nurse suspects a wound infection. The nurse identifies this type of drainage as:
Correct Answer: A
Rationale: The correct answer is A: Purulent. Purulent drainage is thick, yellow, and indicates the presence of infection. This type of drainage is typically seen in infected wounds. Choice B, Serous drainage, is thin, clear, and watery, which is normal in the initial stages of wound healing. Sanguineous drainage, choice C, is bright red and indicates fresh bleeding. Serosanguineous drainage, choice D, is pale pink to red and is a mixture of blood and serous fluid commonly seen in the early stages of wound healing.
Question 2 of 5
A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?
Correct Answer: A
Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.
Question 3 of 5
A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?
Correct Answer: B
Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').
Question 4 of 5
What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?
Correct Answer: A
Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.
Question 5 of 5
A client who is postoperative following abdominal surgery has an eviscerated wound. What should the nurse do first?
Correct Answer: A
Rationale: The initial action the nurse should take after discovering a client's eviscerated wound is to cover the incision with a moist sterile dressing. This step is crucial to protect the exposed tissue, prevent infection, and create a conducive environment for healing. While notifying the surgeon is important, addressing the wound immediately takes precedence. Assessing vital signs is essential but should follow the immediate intervention of covering the wound. Placing the client in a supine position with knees bent is not the priority in managing an eviscerated wound; the first step is to cover the wound to protect the exposed tissue.