Question

A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the practical nurse (PN) reinforce to the client regarding controlling the transmission of TB?

Answer 1

Correct Answers:

Proper disposal of tissues when coughing.

Rationale :

🔷 Active tuberculosis is transmitted through airborne droplets when the infected client coughs, sneezes, speaks, or laughs.

🔷 Proper disposal of tissues helps reduce contamination from respiratory secretions and limits spread of infectious particles.

🔷 The client should cover the mouth and nose when coughing, dispose of tissues immediately, and perform hand hygiene afterward.

🔷 The PN should reinforce infection-control measures such as wearing a mask when directed and following airborne precautions.

🔷 Teaching cough etiquette is directly related to controlling TB transmission.

Importance of an adequate diet.

🔷Adequate nutrition supports healing and immune function, but it does not directly prevent spread of airborne TB.

🔷Transmission control focuses on respiratory hygiene, airborne precautions, and medication adherence.

Side effects of antitubercular medications.

🔷Medication side effects are important teaching, especially hepatotoxicity and vision changes depending on the drug.

🔷However, this does not directly answer how to control immediate transmission.

Complications of the disease.

🔷Complications help the client understand disease seriousness, but they do not provide a direct prevention action.

🔷The priority teaching for transmission is proper handling of respiratory secretions.

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Answer 2

Correct Answers:

Seek a safe place if sensing dizziness or sensory disturbances.
Stay well rested and avoid a large caffeine intake.
Avoid flashing lights and excessive visual stimuli.

Rationale :

Seek a safe place if sensing dizziness or sensory disturbances

🔶 Dizziness, unusual smells, visual changes, or sensory disturbances may be an aura, which can occur before a seizure.

🔶 Seeking a safe place can reduce the risk of injury if the seizure progresses.

🔶 The client should move away from stairs, water, traffic, sharp objects, or machinery.

🔶 This action promotes safety while allowing the client time to sit or lie down.

🔶 Recognizing warning signs is an important part of seizure self-management.

Stay well rested and avoid a large caffeine intake

🔶 Sleep deprivation is a common seizure trigger because it increases brain irritability and lowers the seizure threshold.

🔶 Excessive caffeine can contribute to poor sleep, nervous system stimulation, and dehydration.

🔶 Maintaining a regular sleep schedule supports neurologic stability.

🔶 The client should avoid skipped meals, excessive alcohol, and medication nonadherence because these can also increase seizure risk.

🔶 Adequate rest and reduced stimulant intake help prevent seizure episodes.

Avoid flashing lights and excessive visual stimuli

🔶 Flashing lights can trigger seizures in clients with photosensitive epilepsy.

🔶 Excessive visual stimulation from video games, strobe lights, or rapidly changing screens may increase seizure risk in susceptible clients.

🔶 The client should reduce exposure to known triggers and use protective strategies when unavoidable.

🔶 Trigger avoidance is an important part of seizure prevention along with medication adherence.

🔶 This teaching helps the client reduce environmental factors that may provoke seizure activity.

Carry phone number of Epilepsy Foundation at all times.

🔶Having support resources may be helpful, but it does not directly prevent seizure episodes.

🔶Prevention focuses on safety planning, avoiding triggers, and taking antiseizure medications as prescribed.

Generic medications are safe to substitute for trade name brands.

🔶Switching between antiseizure medication brands or formulations can alter blood levels in some clients.

🔶The client should consult the provider before changing medication products.

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Answer 3

Correct Answers:

Position the client to prevent aspiration.

Rationale :

💎 In the acute phase after a cerebrovascular accident, airway protection is the highest priority.

💎 Stroke can impair swallowing, gag reflex, facial movement, and level of consciousness, increasing risk for aspiration.

💎 Positioning the client properly helps prevent saliva, food, fluids, or vomitus from entering the lungs.

💎 Aspiration can quickly lead to airway obstruction, pneumonia, hypoxia, and further neurologic injury.

💎 The nurse should keep the client safely positioned and ensure swallowing ability is assessed before oral intake.

Monitor the client’s level of consciousness.

💎Level of consciousness is very important after a CVA because changes can indicate neurologic deterioration.

💎However, airway and aspiration prevention take priority in the acute phase.

Apply bilateral compression stockings.

💎Compression stockings help reduce the risk of venous thromboembolism during immobility.

💎This is important but not higher priority than protecting the airway.

Measure intake and output every 8 hours.

💎Fluid balance monitoring is helpful, especially if dysphagia or IV fluids are involved.

💎It is not the highest priority compared with preventing aspiration.

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Answer 4

Correct Answers:

Explains importance of wearing protective clothing when outdoors.

Rationale :

🟣 Lyme disease is transmitted through the bite of infected Ixodes ticks, commonly found in grassy, wooded, or brushy areas.

🟣 Wearing protective clothing outdoors helps reduce skin exposure and lowers the risk of tick attachment.

🟣 Long sleeves, long pants, socks, closed shoes, and tick repellent are important preventive measures.

🟣 The client should also check the skin after outdoor activity and remove ticks promptly with proper technique.

🟣 This outcome is appropriate because Lyme disease education focuses on preventing future tick bites.

States the importance of maintaining current immunization schedule.

🟣Routine immunizations are important for general health but do not prevent Lyme disease.

🟣Prevention focuses on tick avoidance and early tick removal.

Demonstrates disposal of personal tissues in no touch receptacle.

🟣Tissue disposal is more relevant to respiratory infections.

🟣Lyme disease is not spread through respiratory secretions.

Wears a mask each time when leaving the room.

🟣Masks are not needed for Lyme disease because it is not airborne or droplet transmitted.

🟣 It is transmitted through infected tick bites.

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Answer 5

Correct Answers:

Place soiled linen in a leak proof laundry bag.

Rationale :

🟠 Blood-contaminated linen should be handled using standard precautions to prevent exposure to bloodborne pathogens.

🟠 Placing the linen in a leak-proof laundry bag prevents blood or body fluids from leaking during transport.

🟠 Linen should be handled as little as possible and should not be shaken because this can spread microorganisms.

🟠 The PN should wear gloves and perform hand hygiene after removing gloves.

🟠 This action safely contains contaminated linen without unnecessary special handling.

Send soiled linen to laundry in a red biohazard bag.

🟠A red biohazard bag is generally used for regulated medical waste, not routine soiled linen.

🟠Linen is usually placed in designated leak-proof laundry bags according to facility policy.

Rinse soiled linen with water before sending it to laundry.

🟠Rinsing linen increases exposure risk and can splash contaminated fluids.

🟠Soiled linen should be contained, not rinsed by staff.

Double bag soiled linen to be put in a biohazard box.

🟠Double bagging is only needed if the outside of the bag is contaminated or leaking.

🟠A biohazard box is not appropriate for routine contaminated linen.

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Answer 6

Correct Answers:

Observe the skin around the wound.

Rationale :

🔵 Cellulitis is an infection of the skin and subcutaneous tissue, so assessment should focus on the skin surrounding the wound.

🔵 The PN should observe for redness, warmth, swelling, tenderness, induration, and spreading inflammation.

🔵 The borders of redness may be marked to monitor whether the infection is improving or worsening.

🔵 Systemic findings such as fever, chills, increased pain, or tachycardia may suggest worsening infection.

🔵 Careful skin assessment helps detect progression and response to treatment.

Note the color of the wound drainage.

🔵Drainage color may provide information about wound infection, but cellulitis is primarily assessed by surrounding skin changes.

🔵 The most direct finding is redness, warmth, swelling, and tenderness around the wound.

Blanch the tissue distal to the wound.

🔵Blanching distal tissue assesses circulation, not cellulitis.

🔵 Cellulitis assessment focuses on inflammatory changes around the infected area.

Measure the amount of granulation.

🔵Granulation tissue reflects wound healing.

🔵It does not directly assess the extent of cellulitis in surrounding tissue.

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Answer 7

Correct Answers:

Notify the healthcare provider (HCP).

Rationale :

🟢 Hypotension, tachycardia, tachypnea, fever, and cool moist skin in a client with bacterial pneumonia suggest possible sepsis or septic shock.

🟢 These findings indicate impaired perfusion and a systemic response to infection.

🟢 Pneumonia can progress rapidly to sepsis, especially when vital signs become unstable.

🟢 The PN should notify the healthcare provider promptly so treatment such as oxygen, IV fluids, cultures, antibiotics, and further evaluation can be initiated.

🟢 Early recognition and reporting are essential to prevent worsening shock and organ dysfunction.

Provide clear oral fluids and ice chips.

🟢Oral fluids may be inappropriate if the client is unstable, short of breath, or at risk for aspiration.

🟢The priority is urgent provider notification due to signs of systemic deterioration.

Give prescribed acetaminophen.

🟢Acetaminophen may reduce fever, but it does not address hypotension and possible sepsis.

🟢The unstable vital signs require immediate escalation of care.

Document the assessment findings.

🟢Documentation is necessary, but it should not delay reporting urgent changes.

🟢The client’s findings suggest a potentially life-threatening complication.

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Answer 8

Correct Answers:

Space small meals throughout the day.

Rationale :

🟡 Chemotherapy commonly causes nausea and vomiting because it irritates the gastrointestinal tract and stimulates the vomiting center.

🟡 Small, frequent meals are easier to tolerate than large meals.

🟡 Spacing meals throughout the day helps reduce gastric fullness and decreases nausea triggers.

🟡 The client should also avoid greasy, spicy, strong-smelling, or overly sweet foods if they worsen symptoms.

🟡 This teaching supports nutrition and hydration during chemotherapy treatment.

Increase intake of fiber rich foods.

🟡Fiber may help constipation, but it is not the best intervention for chemotherapy-related nausea and vomiting.

🟡High-fiber foods can worsen bloating or discomfort in some clients.

Limit intake of all types of liquids.

🟡Limiting liquids can worsen dehydration, especially when vomiting occurs.

🟡 The client should take small, frequent sips of fluids as tolerated.

Eat three well-balanced meals a day.

🟡Three larger meals can increase nausea because the stomach becomes too full.

🟡 Small frequent meals are usually better tolerated during chemotherapy.

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Answer 9

Correct Answers:

Grilled salmon and a cup of black coffee.

Rationale :

🔴 This meal is appropriate because grilled salmon provides heart-healthy protein and beneficial omega-3 fatty acids.

🔴 The client has low HDL and high LDL, so diet teaching should focus on reducing saturated fat, trans fat, fried foods, and excess cholesterol.

🔴 Salmon is a better choice than fried or high-fat foods because it supports cardiovascular health.

🔴 Black coffee does not add saturated fat, sugar, or cholesterol when consumed without cream or sugar.

🔴 This selection best supports lipid control while the client is taking atorvastatin.

Fried chicken, a salad, and a glass of water.

🔴Fried chicken is high in fat and can increase intake of unhealthy oils and calories.

🔴It is not the best choice for a client with elevated LDL.

A slice of cheese pizza and a soft drink.

🔴Cheese pizza is high in saturated fat and sodium, and soft drinks add excess sugar.

🔴 This meal does not support lipid-lowering dietary goals.

A bowl of oatmeal and a cup of grapefruit juice.

🔴Oatmeal is heart-healthy, but grapefruit juice can interact with atorvastatin and increase the risk of medication toxicity.

🔴The client should avoid grapefruit products while taking many statins unless approved by the provider.

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Answer 10

Correct Answers:

Bend the unaffected leg while maintaining the affected leg in traction.

Rationale :

🟤 Buck’s traction must be maintained to keep proper alignment and reduce muscle spasm in the fractured hip.

🟤 During catheter insertion, the affected leg should remain in traction to prevent displacement, pain, or further injury.

🟤 Bending only the unaffected leg allows access for catheterization while protecting the injured extremity.

🟤 The PN should avoid removing or altering traction unless specifically prescribed by the healthcare provider.

🟤 Maintaining traction during care supports fracture stabilization and client safety.

Turn the client to the affected side and bend only the unaffected leg.

🟤Turning the client onto the affected side can disrupt alignment and increase pain.

🟤The affected leg should remain supported and in traction.

Ensure that both legs remain straight and externally rotated.

🟤External rotation is not appropriate positioning for a hip fracture in Buck’s traction.

🟤This position can worsen alignment and does not provide adequate access for catheterization.

Remove the traction and assist the client to bend both legs at the knees.

🟤The PN should not remove traction without a provider order.

🟤Bending the affected leg can worsen pain, disrupt fracture alignment, and compromise treatment.

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HESI LPN

No.

1 :
A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the practical nurse (PN) reinforce to the client regarding controlling the transmission of TB?

2 :
A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. Which information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

3 :
Which intervention has the highest priority for a client in the acute phase following a cerebrovascular accident (CVA)?

4 :
The practical nurse (PN) is contributing to a plan of care (POC) for an adult client with Lyme disease. Which client outcome is indicated for this client?

5 :
While assisting a client with a diagnosis of AIDS with basic hygiene care, the practical nurse (PN) observes a small amount of blood on the sheets. Which action should the PN take?

6 :
The nurse is caring for a client with cellulitis from a stab wound. To assess the cellulitis, which action should the practical nurse (PN) take?

7 :
The practical nurse (PN) performs a focused assessment on a client with bacterial pneumonia. During the assessment, the PN discovers hypotension, an elevated heart rate, respiratory rate, and temperature. The client's skin is cool and moist to touch. Which action should the PN take next?

8 :
The practical nurse (PN) is reviewing discharge instructions with a client who is receiving chemotherapy. Which instruction should the PN reinforce to help the client manage nausea and vomiting after receiving chemotherapy?

10 :
The practical nurse (PN) plans to insert indwelling urinary catheter in a female client with Buck's traction for a left hip fracture. To perform the catheterization, which action should the PN take?

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HESI LPN

No.

1 : A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the practical nurse (PN) reinforce to the client regarding controlling the transmission of TB?

2 : A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. Which information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

3 : Which intervention has the highest priority for a client in the acute phase following a cerebrovascular accident (CVA)?

4 : The practical nurse (PN) is contributing to a plan of care (POC) for an adult client with Lyme disease. Which client outcome is indicated for this client?

5 : While assisting a client with a diagnosis of AIDS with basic hygiene care, the practical nurse (PN) observes a small amount of blood on the sheets. Which action should the PN take?

6 : The nurse is caring for a client with cellulitis from a stab wound. To assess the cellulitis, which action should the practical nurse (PN) take?

7 : The practical nurse (PN) performs a focused assessment on a client with bacterial pneumonia. During the assessment, the PN discovers hypotension, an elevated heart rate, respiratory rate, and temperature. The client's skin is cool and moist to touch. Which action should the PN take next?

8 : The practical nurse (PN) is reviewing discharge instructions with a client who is receiving chemotherapy. Which instruction should the PN reinforce to help the client manage nausea and vomiting after receiving chemotherapy?

10 : The practical nurse (PN) plans to insert indwelling urinary catheter in a female client with Buck's traction for a left hip fracture. To perform the catheterization, which action should the PN take?

1 :
A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the practical nurse (PN) reinforce to the client regarding controlling the transmission of TB?

2 :
A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. Which information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

3 :
Which intervention has the highest priority for a client in the acute phase following a cerebrovascular accident (CVA)?

4 :
The practical nurse (PN) is contributing to a plan of care (POC) for an adult client with Lyme disease. Which client outcome is indicated for this client?

5 :
While assisting a client with a diagnosis of AIDS with basic hygiene care, the practical nurse (PN) observes a small amount of blood on the sheets. Which action should the PN take?

6 :
The nurse is caring for a client with cellulitis from a stab wound. To assess the cellulitis, which action should the practical nurse (PN) take?

7 :
The practical nurse (PN) performs a focused assessment on a client with bacterial pneumonia. During the assessment, the PN discovers hypotension, an elevated heart rate, respiratory rate, and temperature. The client's skin is cool and moist to touch. Which action should the PN take next?

8 :
The practical nurse (PN) is reviewing discharge instructions with a client who is receiving chemotherapy. Which instruction should the PN reinforce to help the client manage nausea and vomiting after receiving chemotherapy?

10 :
The practical nurse (PN) plans to insert indwelling urinary catheter in a female client with Buck's traction for a left hip fracture. To perform the catheterization, which action should the PN take?