HESI Fundamentals Test Bank

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The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's disease. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?

  • A. Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care.
  • B. Develop a chart for the client, listing the times the medication should be taken.
  • C. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.
  • D. Instruct the client and client's children to put medications in a weekly pill organizer.
Correct Answer: C

Rationale: The priority nursing intervention in this scenario is to contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Simplifying the medication regimen is crucial for a client with early Alzheimer's disease to ensure they can manage their medications independently and safely. This intervention focuses on optimizing the client's ability to adhere to the prescribed medication schedule. Choices A and D involve external assistance and may not address the core issue of simplifying the regimen. Choice B, while helpful, does not directly address the need to simplify the regimen to enhance the client's medication management.

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The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

  • A. Nasal congestion
  • B. Cough
  • C. Sore throat
  • D. Fatigue
Correct Answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

  • A. Evacuate the client
  • B. Attempt to extinguish the fire
  • C. Call the fire department
  • D. Close the door to contain the fire
Correct Answer: A

Rationale: The correct answer is to Evacuate the client (Choice A). In the event of a fire, the safety of the client is the top priority. The RACE (Rescue, Alarm, Contain, Extinguish) mnemonic is used in fire emergencies. The first step is to Rescue or Evacuate the individual from immediate danger. Attempting to extinguish the fire (Choice B) may endanger both the client and the nurse. Calling the fire department (Choice C) is important but should come after ensuring the client's safety. Closing the door to contain the fire (Choice D) is not appropriate in this scenario because the priority is to remove the client from harm's way.

A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

  • A. Dietitian consult
  • B. Speech therapy referral
  • C. Oral suction at the bedside
  • D. Clear liquids
Correct Answer: D

Rationale: The correct answer is D: 'Clear liquids.' Clients with dysphagia following a stroke are at risk of aspiration, and clear liquids have a higher risk of aspiration compared to thickened liquids or pureed foods. Therefore, the nurse should clarify the prescription for clear liquids to prevent potential harm to the client. Choices A, B, and C are appropriate interventions for a client with dysphagia following a stroke. A dietitian consult can help modify the client's diet for safe swallowing, speech therapy can assist in improving swallowing function, and oral suction at the bedside helps maintain airway patency and prevents aspiration.

The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

  • A. Administer antibiotic therapy for 10 days
  • B. Teach the client isometric exercises for legs
  • C. Assess movement and sensation of extremities
  • D. Assist the client to stand up at the bedside within the first 24 hours
Correct Answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

  • A. Apply the stockings with the creases on the front of the leg.
  • B. Apply the stockings while the client's legs are in a dependent position.
  • C. Remove the stockings at least once per shift.
  • D. Remove the stockings while the client is sitting in a reclining chair.
Correct Answer: C

Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.

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