HESI LPN
HESI Fundamentals Exam Test Bank Questions
Question 1 of 9
While caring for a client receiving parenteral fluid therapy via a peripheral IV catheter, after which of the following observations should the nurse remove the IV catheter?
Correct Answer: A
Rationale: Swelling and coolness at the IV site can indicate complications such as infiltration, which can lead to tissue damage or fluid leakage into the surrounding tissues. Prompt removal of the IV catheter is essential to prevent further complications. The client reporting mild discomfort at the insertion site is common during IV therapy and does not necessarily warrant catheter removal unless there are signs of infiltration. A slower than expected infusion rate may not always necessitate IV catheter removal; the nurse should troubleshoot potential causes such as kinks in the tubing or pump malfunctions first. Just because the IV catheter is no longer needed for treatment does not automatically mean it should be removed; proper assessment and monitoring for complications are still essential.
Question 2 of 9
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?
Correct Answer: D
Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.
Question 3 of 9
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.
Question 4 of 9
What is the most important action for preventing infection in a client with a central venous catheter?
Correct Answer: D
Rationale: Maintaining sterile technique when handling a central venous catheter is crucial in preventing infections. This action helps minimize the introduction of pathogens into the catheter site, reducing the risk of contamination and subsequent infection. Changing the catheter dressing every 72 hours, while important, does not directly address the prevention of infection at the insertion site. Flushing the catheter with heparin solution daily helps prevent occlusion but does not primarily focus on infection prevention. Ensuring the catheter is clamped when not in use is essential for preventing air embolism but does not directly relate to infection control.
Question 5 of 9
When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?
Correct Answer: C
Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.
Question 6 of 9
A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
Correct Answer: D
Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.
Question 7 of 9
When changing the client's dressing, which observation should the nurse report to the client's surgeon for a client recovering from an appendectomy for a ruptured appendix with a surgical wound healing by secondary intention?
Correct Answer: A
Rationale: A halo of erythema on the surrounding skin may indicate an infection or inflammation of the wound site, which is critical to report to the surgeon. Erythema, redness, and warmth are signs of inflammation that could potentially be a sign of an infected wound. Serous drainage is a common and expected finding in healing wounds, indicating a normal healing process. Edema around the wound might be expected due to the body's response to tissue injury. The absence of granulation tissue in a wound healing by secondary intention may not be an immediate concern as it forms during the later stages of wound healing.
Question 8 of 9
The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
Correct Answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
Question 9 of 9
When administering otic ear medication to an adult client, what action should be done to ensure the medication reaches the inner ear?
Correct Answer: A
Rationale: The correct action to ensure the medication reaches the inner ear is to press gently on the tragus of the client's ear. The tragus is the small pointed eminence of the external ear, and pressing on it helps direct the medication deeper into the ear canal. Pulling the ear lobe up and back (Choice B) is the correct technique for administering eardrops to a child, not an adult. Inserting the medication deeply into the ear canal (Choice C) can cause injury or discomfort as the eardrops are designed to flow into the ear canal naturally. Massaging the ear gently after administering the medication (Choice D) is unnecessary and may not help the medication reach the inner ear effectively.